v* 



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GENERAL SURGICAL 



PATHOLOGY AND THERAPEUTICS 



|n Jfx%-0tt£ $ettttws. 



A TEXT-BOOK FOR STUDENTS AND PHYSICIANS. 



BY / 

Dr. THEODOK BILLROTH, 

PROFESSOR OF SURGERY IN VIENNA. 



TRANSLATED FROM THE FOURTH GERMAN EDITION, WITH THE SPECIAL PERMISSION OF THE 
AUTHOR, AND REVISED FROM THE EIGHTH EDITION, BY 



CHARLES E. HACKLEY, A. M., M. D., 

PHYSICIAN TO THE NEW YORK HOSPITAL, FELLOW OF THE NEW YORK 
ACADEMY OF MEDICINE, ETC., ETC. 



^O0PYRi6W?^R 



[{jvo.JjAZJtjj 

\ fa 1879. W 
NEW YOKK: 



D. APPLETON AND COMPANY, 

549 & 551 BROADWAY. 
1879. 



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Entered, according to Act of Congress, in the year 1871, by Charles E. Hacxley, in the 
Office of the Librarian of Congress, at Washington. 



Entered, according to Act of Congress, in the year 1873, by Charles E. Hacklet, in the 
Office of the Librarian of Congress, at Washington. 



Entered, according to Act of Congress, in the year 1879, by Charles E. Hackley, in the 
Office of the Librarian of Congress, at Washington. 



TRANSLATOR'S PREFACE TO THE REVISED EDITION. 



Since this translation was revised from the sixth German 
edition in 1874, two other German editions have been pub- 
lished. The present revision is made to correspond to the eighth 
German edition. In order to make use of the stereotype plates 
of the former edition as far as possible, some of the additions 
have been inserted in an appendix. These are numbered, and 
are referred to in the text by corresponding numbers. 

Lister's method of antiseptic treatment is referred to in 
various places ; and other new points that have come up within 
a few years are discussed. A chapter has been written on ampu- 
tations and resections. In all there are seventy-four additional 
pages, with a number of new woodcuts. 

CHAS. E. HACKLEY, M.D. 

New York, December, 1878. 



TRANSLATOR'S PREFACE. 



During the past ten years the microscope has greatly ad- 
vanced our knowledge of Pathology; and it will perhaps be 
acknowledged that most progress in the study of Pathological 
Anatomy has been made in Germany. 

Prof. Theodor Billroth, himself one of the most noted au- 
thorities on Surgical Pathology, has in the present volume given 
us a complete resume of the existing state of knowledge in this 
branch of medical science. 

The book might perhaps have been entitled " Principles of 
Surgery," but this would hardly have indicated the specific man- 
ner in which these principles have been inculcated. 

Most of the views found in these lectures have been floating 
through the journals for several years past ; but, so far as the 
translator knows, they are not so fully presented in any book in 
the English language. The only work in our language on the 
subject was published many years ago ; even the late editions 
are but little changed from the first ; moreover, the two works 
are, in most respects, entirely unlike. 

The fact of this publication going through four editions in 
Germany, and having been translated into French, Italian, Rus- 
sian, and Hungarian, should be some guarantee for its standing. 

Some few notes that have been inserted by the translator 
will be found enclosed in brackets [ ]. 

New York, December 1, 1870. 



PREFACE TO THE EIGHTH GERMAN EDITION. 



This edition also lias been carefully revised, and some addi- 
tions have been made to it. It is the hope of the author that 
the book will continue to be acceptable and beneficial to students 
of surgery. 

In addition to previous translations, there has been a new 
English one made under the auspices of the New Sydenham 
Society, as well as one into Japanese by Dr. Susum Sato. 

TH. BILLEOTH. 



AUTHOR'S PREFACE TO THE SIXTH EDITION. 



The steady advance of science, and the progress that we onr 
selves make as long as we have the inclination and strength to 
swim with the stream, become most apparent when we are from 
time to time obliged to go over our old work. On a similar 
occasion I have already expressed this thought, but do not hesi- 
tate to repeat it here ; for this perception of progress is a great 
support to us in the many dark hours when, with the greatest 
zeal to serve our fellow-men, we feel oppressed by the impotence 
of our knowledge and ability. 

I have again done my best to raise this book to the present 
level of our knowledge, and have untiringly striven to improve 
its form and contents ; the section on Deformities has been en- 
tirely rewritten, old woodcuts have been replaced by better 
ones, and some new ones have been added ; prescriptions have 
been given in grammes. 

May this enlarged edition also be well received, and arouse 
in the student a love of surgery ! 

TH. BILLROTH. 

Vienna, November, 1872. 



PREFACE TO THE FOURTH EDITION. 



Almost every time that it has become my pleasant task to 
go over this book in preparing a new edition, I have thought, 
this time at least, there will not be mnch to alter ; nevertheless, 
I always found much, very much to improve, to cut out or to 
add. In so doing, I have always had the satisfaction of knowing 
that even in short periods the progress of science had been quite 
perceptible. We do not notice this much while swimming with 
the stream, but it becomes very evident when we have before us 
a book that is to a certain extent a photogram of the state of 
affairs two years since. The success that this edition meets 
with will show whether I have again succeeded in presenting 
my book in a shape to meet the requirements of physicians and 
students. 

The section on traumatic inflammation has been revised in 
accordance with recent advances. In the chapter on tumors, 
the part treating of carcinoma has been simplified, the term 
" connective-tissue cancer " being omitted, to prevent confusion. 

The liberality of the publisher has enabled me to increase 
the number of woodcuts by twenty-nine (Figs. 47, 53, 55, 58, 66, 
68, 69, TO, 74, 91, 98, 99, 103, 106, 107, 108, 109, 110, 111, 112, 
122, 123, 124, 125, 126, 127, 128, 132, 133). 

De. TH. BILLROTH. 
A^ienna, November, 1869. 



CONTENTS. 



LECTUEE L 



INTRODUCTION. 



Relation of Surgery to Internal Medicine. — Necessity of the Practising Physician 
being acquainted with both. — Historical Bemarks. — Nature of the Study of Sur- 
gery in the German High-school, page 1 



CHAPTER I. 

SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

LECTUEE II. 

Mode of Origin and Appearance of theae "Wounds. — Various Forms of Incised "Wounds. 
— Appearance during and immediately after their Occurrence. — Pain, Bleeding. — 
Varieties of Haemorrhage ; Arterial, Venous. — Entrance of Air through "Wounded 
Veins. — Parenchymatous Haemorrhage. — Haemorrhagic Diathesis. — Haemorrhage 
from the Pharynx and Eectum. — Constitutional Effects of Severe Haemor- 
rhage, p. 17 

LECTUEE III. 

Treatment of Haemorrhage. — 1. Ligature and Mediate Ligature of Arteries. — 2. Com- 
pression by the Finger ; Choice of the Point for Compression of the Larger Arte- 
ries. — Tourniquet. — Acupressure. — Bandaging. — Tampon. — 3. Styptics. — General 
Treatment of Sudden Anaemia. — Transfusion, . .... p. 26 

LECTUEE IV. 

Gaping of the "Wound. — Union by Plaster. — Suture ; Interrupted Suture ; Twisted Su- 
ture. — External Changes perceptible in the United "Wound. — Healing by First In- 
tention, p. 41 

LECTUEE V. 

The more Minute Changes in Healing by the First Intention.— Dilatation of Vessels in 
the Vicinity of the "Wound. — Fluxion. — Different Views regarding the Causes of 
Fluxion, p. 49 

LECTUEE VI. 

Changes in the Tissue during Healing by the First Intention. — Plastic Infiltration. — 
Inflammatory New Formation. — Eetrogression to the Cicatrix. — Anatomical Evi- 



x CONTENTS. 

dences of Inflammation. — Conditions under which Healing by First Intention does 
not occur.— Union of Parts that have been completely separated, . . page 58 

LECTUEE VII. 

Changes perceptible to the Naked Eye in Wounds with Loss of Substance.— Finer Pro- 
cesses in Healing with Granulation and Suppuration. — Pus. — Cicatrization. — Obser- 
vations on "Inflammation." — Demonstration of Preparations illustrative of the 
Healing of Wounds, p. 70 

LECTUEE VIII. 

General Eeaction after Injury. — Surgical Fever. — Theories of the Fever. — Prognosis. — 
Treatment of Simple Wounds and of Wounded Persons. — Burrowing Wounds. — 
Open Treatment of Wounds.— Lister's Method.— Coccobacteria Septica, . p. 88 

LECTUEE IX. 

Combination of Healing by First and Second Intention. — Union of Granulation Surfaces. 
Healing under a Scab. — Granulation Diseases. — The Cicatrix in Various Tissues ; in 
Muscle; in Nerve; its Knobby Proliferation; in Vessels. — Organization of the 
Thrombus. — Arterial Collateral Circulation, . . . . . . . p. 99 



CHAPTER II. 

SOME PECULIARITIES OF PUNCTURED WOUNDS. 

LECTUEE X. 

As a Eule, Punctured Wounds heal quickly by First Intention. — Needle Punctures ; 
Needles remaining in the Body, their Extraction. — Punctured Wounds of the Nerves. 
— Punctured Wounds of the Arteries : Aneurysma Traumaticum, Varicosum, Varix 
Aneurysmaticus. — Punctured Wounds of the Veins, Venesection, . .p. 130 



CHAPTER III. 

CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 

LECTUEE XI. 

Causes of Contusions. — Nervous Concussion. — Subcutaneous Eupture of Vessels. — Bup 
ture of Arteries.— Suggillations. — Ecchymoses. — Eeabsorption. — Termination in 
Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction. — Treatment, p. 141 



CHAPTER IV. 

CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

LECTUEE XII. 

Mode of Occurrence of these Wounds ; their Appearance. — Slight Haemorrhage in Con- 
tused Wounds. — Early Secondary Haemorrhages. — Gangrene of the Edges of the 
Wound. — Influences that effect the Slower or more Eapid Detachment of the Dead 
Tissue. — Indications for Primary Amputation. — Local Complications in Contused 
Wounds ; Decomposition, Putrefaction, Septic Inflammations.— Contusion of Ar- 
teries ; Late Secondary Haemorrhages, p. 152 



CONTEXTS. xi 

LECTUKE XIII. 

Progressive Suppuration starting from Contused Wounds. — Secondary Inflammations 
of the "Wound: their Causes; Local Infection. — Febrile Eeaction in Contused 
Wounds : Secondary Fever ; Suppurative Fever ; Chill ; their Causes. — Treatment 
of Contused "Wounds : Immersion, Ice-bladders, Irrigation ; Criticism of these 
Methods. — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open Treat- 
ment of "Wounds. — Prophylaxis against Secondary Inflammations. — Internal Treat- 
ment of those severely "Wounded. — Quinine. — Opium. — Lacerated "Wounds : Sub- 
cutaneous Eupture of Muscles and Tendons ; Tearing out of Muscles and Tendons ; 
Tearing out of Pieces of a Limb, page 164 



CHAPTER Y. 

SIMPLE FRACTURES OF BOXES 

LECTUKE XIV. 

Causes, Different Varieties of Fractures. — Symptoms, Diagnosis.— Course and External 
Symptoms. — Anatomy of Healing, Formation of Callus.— Source of the Inflamma- 
tory Osseous New Formation. — Histology, p. 185 

LECTUEE XV. 

Treatment of Simple Fractures.— Eeduction. — Time for applying the Dressing, its 
Choice. — Plaster of Paris and Starch Dressings, Splints, Permanent Extension. — 
Eetaining the Limb in Position. — Indications for removing the Dressings, p. 201 



CHAPTER VI. 

OPEN FRACTURES AND SUPPURATION OF BONE. 

Difference between Subcutaneous and Open Fractures in regard to Prognosis. — Vari- 
eties of Cases. — Indications for Primary Amputation. — Secondary Amputation. — 
Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Frag- 
ments, p. 210 

LECTUEE XVI. 

Development of Osseous Granulations. — Histology. — Detachment of the Sequestrum. — 
Histology. — Osseous New Formation around the Detached Sequestrum. — Callus in 
Suppurating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Con- 
dition. — Fever. — Treatment ; Fenestrated, Closed, Split Dressings. — Antiphlogis- 
tic Eemedies. — Immersion. — Lister's Method. — Eules about Bone-splinters. — 
After-Treatment, . p. 216 

APPENDIX TO CHAPTERS V. AND VI. 

LECTUEE XVII. 

1. Eetarded Formation of Callus and Development of Pseudarthrosis.— Causes often 
unknown. — Local Causes. — Constitutional Causes. — Anatomical Conditions. — 
Treatment: internal, operative; Criticism of Methods. 2. Obliquely-united 
Fractures; Eebreaking, Bloody Operations. — Abnormal Development of Cal- 
lus, p. 226 



xii CONTENTS. 

CHAPTER VII. 

INJURIES OF THE JOINTS. 

Contusion.— Distortion.— Massage. — Opening of the Joint, and Acute Traumatic Ar- 
ticular Inflammation. — Variety of Course, and Kesults. — Treatment. — Anatomical 
Changes, page 234 

LECTUEE XVI11. 

Simple Dislocations; Traumatic, Congenital, Pathological Luxations, Subluxations. — 
Etiology. — Difficulties in Eeduction, Treatment; Eeduction, After-Treatment. — 
Habitual Luxations. — Old Luxations, Treatment. — Complicated Luxations. — Con- 
genital Luxations, p. 242 

CHAPTER VIII. 

G UNSHOT- WOUNDS. 

LECTUEE XIX. 
Historical Eemarks. — Injuries from Large Missiles. — Various Forms of Bullet-Wounds. 
— Transportation and Care of the "Wounded in the Field. — Treatment. — Compli- 
cated Gunshot-Fractures, p. 254 

CHAPTER IX. 

BURNS AND FROST-BITES. 

LECTUEE XX. 
1. Burns: Grade, Extent, Treatment.— Sunstroke.— Stroke of Lightning.— 2. Frost- 
bites : Grade. — General Freezing, Treatment. — Chilblains, . . .p. 266 

CHAPTER X. 

ACUTE NON-TRAUMATIC INFLAMMATION OF THE SOFT PARTS. 
LECTUEE XXI. 
General Etiology of Acute Inflammations.— Acute Inflammation : 1. Of the Cutis. 
a, Erysipelatous Inflammation ; J, Furuncle ; c, Carbuncle (Anthrax), Pustula Ma- 
ligna. 2. Of the Mucous Membranes. 3. Of the Cellular Tissue, Acute Abscesses. 
4. Of the Muscles. 5. Of the Serous Membranes, Sheaths of the Tendons, and 
Subcutaneous Mucous Bursa?, p. 277 

CHAPTER XI. 

ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, AND JOINTS. 
LECTUEE XXII. 

Anatomy.— Acute Periostitis and Osteomyelitis of the Long Bones : Symptoms, Ter- 
minations in Eesolution, Suppuration, Necrosis, Prognosis, Treatment.— Acute 
Ostitis in Spongy Bones.— Multiple Acute Osteomyelitis.— Acute Inflammations 
of the Joints.— Hydrops Acutus ; Symptoms, Treatment.— Acute Suppurative In- 
flammations of Joints : Symptoms, Course, Treatment, Anatomy.— Acute Articular 
Eheumatism.— Arthritis.— Metastatic Inflammations of Joints (Gonorrhoeal, Py- 
emic, Puerperal), p. 300 

APPENDIX TO CHAPTERS I.-XI. 
Eevicw.— General Eemarks about Acute Inflammation, p. 317 



CONTENTS. xiii 

CHAPTER XII. 

GANGRENE. 

LECTURE XXII I. 
Dry, Moist Gangrene. — Immediate Causes. — Process of Detachment. — Varieties of Gan- 
grene according to the Remote Causes.— 1. Loss of Vitality of the Tissue from 
Mechanical or Chemical Causes. — 2. Complete Arrest of the Afflux and Efflux of 
Blood. — Incarceration. — Continued Pressure. — Decubitus. — Great Tension of the 
Tissue. — 3. Complete Arrest of the Supply of Arterial Blood. — Gangrena Spon- 
tanea. — Gangrena Senilis. — Ergotism. — 4. Noma. — Gangrene in Various Blood- 
Diseases. — Treatment, page 326 



CHAPTER XIII. 

ACCIDENTAL TRAUMATIC AND INFLAMMATORY DISEASES, AND POISONED 

WOUNDS. 

LECTURE XXIV. 
I. Local Diseases which may accompany "Wounds and Other Points of Inflammation : 
1. Progressive Purulent and Purulent Putrid Diffuse Inflammation of Cellular 
Tissue. — 2. Hospital Gangrene. — 3. Traumatic Erysipelas. — 4. Lymphangitis, p. 338 

LECTURE XXV. 

5. Phlebitis ; Thrombosis ; Embolism. — Causes of Venous Thrombosis ; Various Meta- 
morphoses of the Thrombus. — Embolism. — Red Infarction, Embolic Metastatic 
Abscesses.— Treatment, p. 353 

LECTURE XXVI. 
II. — General Accidental Diseases which may accompany "Wounds and Local Inflamma- 
tions. 1. Traumatic and Inflammatory Eever ; 2. Septic Fever and Septicemia ; 
3. Suppurative Fever and Pyemia, p. 362 

LECTURE XXVII. 

4. Tetanus; 5. Delirium Potatorum Traumaticum ; 6. Delirium Nervosum and Mania. — 
Appendix to Chapter XIII. — Poisoned "Wounds ; Insect-bites, Snake-bites ; Infec- 
tion from Dissecting Wounds. — Glanders. — Carbuncle. — Diseases from Mouths 
and Claws of Animals.— Hydrophobia, p. 386 



CHAPTER XIV. 

CHRONIC INFLAMMATION ESPECIALLY OF THE SOFT PARTS. 
LECTURE XXVIII. 
Anatomy: 1. Thickening, Hypertrophy ; 2. Hypersecretion; 3. Suppuration, Cold 
Abscesses, Congestive Abscesses, Fistulas, Ulceration. — Results of Chronic Inflam- 
mation. — General Symptomatology. — Course. p. 403 

LECTURE XXIX. 
General Etiology of Chronic Inflammation. — External Continued Irritation. — Causes in 
the Body. — Empirical Idea of Diatheses and Dyscrasiae.— General Symptomatology 
and Treatment of Morbid Diatheses and Dyscrasiae. 1. The Lymphatic Diathesis 
(Scrofula); 2. Tuberculous Dyscrasia (Tuberculosis); 3. The Arthritic Diathesis ; 
4. The Scorbutic Dyscrasia ; 5. Syphilitic Dyscrasia, . . . .p. 410 



XIV CONTENTS. 

LECTURE XXX. 

Local Treatment of Chronic Inflammation : Eest, Compression, Moist Warmth, Hy- 
dropathic Wraps, Eesorbents, Antiphlogistics, Derivatives, Eontanels, Setons, 
Moxas, the Hot Iron, page 429 



CHAPTER XV. 

ULCERS. 

LECTURE XXXI. 
Anatomy. — External Peculiarities of Ulcers ; Form and Extent, Base and Secretion, 
Edges, Parts around. — Local Treatment according to the Local Condition of the 
Ulcer ; Fungous, Callous, Putrid, Phagedenic, Sinuous Ulcers, Etiology, Contin- 
ued Irritation, Venous Congestion, Dyscrasial Causes, . . . .p. 434 



CHAPTER XVI. 

CHRONIC INFLAMMATION OF THE PERIOSTEUM, OF THE BONE, AND 

NECROSIS. 

LECTUEE XXXII. 

Chronic Periostitis and Caries Superficialis. — Symptoms. — Osteophytes. — Osteoplastic, 
Suppurative Forms. — Anatomy of Caries. — Etiology.— Diagnosis.— Combination 
of Various Forms, p. 448 

LECTUEE XXXIII. 

Primary Central, Chronic Ostitis, or Caries. — Symptoms. — Ostitis Interna Osteoplas- 
ts, Suppurativa, Fungosa. — Abscess of Bone. — Combinations. — Ostitis with Cas- 
eous Metamorphosis. — Tubercles of Bone. — Diagnosis of Caries. — Dislocation of the 
Bones after their Partial Destruction. — Congestion Abscesses. — Etiology, p. 458 

LECTUEE XXXIV. 

Process of Cure in Caries and Congestion Abscesses. — Prognosis.— General Health in 
Chronic Inflammations of the Bone. — Secondary Lymphatic Enlargements. — 
Treatment of Caries and Congestion Abscesses. — Eesections in the Conti- 
nuity, p. 468 

LECTUEE XXXV. 

Necrosis. — Etiology. — Anatomical Conditions in Total and Partial Necrosis. — Symp- 
toms and Diagnosis. — Treatment. — Sequestrotomy, p. 479 

LECTUEE XXXVI. 

Rachitis. — Anatomy. — Symptoms. — Etiology. — Treatment. — Osteomalacia. — Hypertro- 
phy and Atrophy of Bone, p. 495 



CHAPTER XVII. 

CHRONIC INFLAMMATION OF THE JOINTS. 

LECTUEE XXXVII. 
General Remarks on the Distinguishing Characteristics of the Chief Forms. — A. Fun- 
gous and Suppurative Articular Inflammations (Tumor Albus), Symptoms, Anato- 
my, Caries Sicca, Suppuration, Atonic Forms. — Etiology.— Course and Prog- 
nosis, p. 508 



CONTENTS. xv 

LECTURE XXXVIII. 

Treatment of Tumor Albus.— Operations.— Resection of the Joints.— Criticisms on the 
Operations on the Different Joints, page 514 

LECTURE XXXIX. 

B. — Chronic Serous Synovitis. — Hydrops Articulorum Chronicus; Anatomy, Symp- 
toms, Treatment. — Typical recurring Dropsies of the Knee. — Appendix : Chronic 
Dropsies of the Sheaths of the Tendons, Synovial Hernias of the Joints and Sub- 
cutaneous Mucous Bursae, p. 524 

LECTURE XL. 

C. — Chronic Rheumatic Inflammation of the Joints. — Arthritis Deformans. — Malum 
Coxae Senile. — Anatomy, Different Forms, Symptoms, Diagnosis, Prognosis, 
Treatment. — Appendix I. : Foreign Bodies in the Joints : 1. Fibrinous Bodies ; 
2. Cartilaginous and Bony Bodies ; Symptomatology, Operations. — Appendix II. : 
Neuroses of the Joints, p. 534 

LECTURE XLI. 
Anchyloses : Varieties, Anatomy, Diagnosis, Treatment ; Gradual Forced Extension ; 
Operations with the Knife, p. 546 

CHAPTER XVIII. 

CONGENITAL DEFORMITIES OF THE JOINTS DUE TO MUSCULAR AND NER- 
VOUS AFFECTIONS AND CICATRICIAL CONTRACTIONS.- LOX ARTHROSES. 

LECTURE XLII. 
I. Deformities of Intra-uterine Origin due to Disturbances of Development of the 
Joint. — II. Deformities occurring only in Children and Young Persons, caused by 
Impaired Growth of the Joint. — III. Deformities from Contractions, or Paralysis 
of Single Muscles or Groups of Muscles. — IV. Limitation of Movements in the 
Joints from Contraction of Fasciae and Ligaments. — V. Cicatricial Contractions. — 
Treatment. — Extension by Apparatus, Straightening under Anaesthesia. — Com- 
pression.— Tenotomy and Myotomy. — Division of the Fasciae and Articular Liga- 
ments. — Gymnastics and Electricity. — Artificial Muscles. — Supporting Appara- 
tus, p. 558 

CHAPTER XIX. 

VARICES AND ANEURISMS. 
LECTURE XLIII. 
Varices: Various Forms, Causes, Various Localities where they occur, — Diagnosis. — 
Vein-stones. — Varix Fistulae. — Treatment. — Varicose Lymphatics, Lymphorrhoea. 
— Aneurisms : Inflammation of Arteries. — Aneurysma Cirsoideum. — Atheroma. — 
Various Forms of Aneurism. — Their Subsequent Changes, — Symptoms, Results, 
Etiology, Diagnosis. — Treatment: Compression, Ligation, Injection of Liquor 
Ferri, Extirpation, p. 576 

CHAPTER XX. 

TUMORS. 

LECTURE XLIV. 

Definition of the Term Tumor. — General Anatomical Remarks; Polymorphism of 

Tissues. — Points of Origin of Tumors. — Limitation of the Development of Cells to 

Certain Types of Tissue. — Relation to the Generative Layers. — Mode of Growth. — 

Anatomical Metamorphosis of Tumors; their External Appearances, . . p. 595 



xvi CONTENTS. 



LECTUEE XLV. 



Etiology of Tumors ; Miasmatic Influence. — Specific Infection.— Specific Eeaction of 
the Irritated Tissues ; its Cause is always constitutional.— Internal Irritations ; 
Hypotheses as to the Character and Mode of the Irritant Action. — Course and 
Prognosis : Solitary, Multiple, Infectious Tumors. — Dyscrasia. — Treatment. — Prin- 
ciples of the Classification of Tumors, ....... page 605 

LECTUEE XLVI. 

1. Fibromata: a, Soft; b, Hard Fibroma. — Mode of Occurrence ; Operations; Ligature; 
Ecrasement ; Galvano-caustic. — 2. Zipomata : Anatomy ; Occurrence ; Course. 3. 
Chondromata: Occurrence; Operation. — 4. Osteomata: Forms; Operation, p. 618 

LECTUEE XLVII. 
5. Myoma. — 6. Neuroma. — 7. Angioma: a, Plexiform; J, Cavernous. — Operations, p. 637 

LECTUEE XLVIH. 

9. Sarcomata.— Anatomy : a, Granulation Sarcoma ; 5, Spindle-celled Sarcoma ; c, Giant- 

celled Sarcoma ; d, Stellate Sarcoma ; e, Alveolar Sarcoma ; y, Pigmented Sarcoma. 
— Clinical Appearance. — Diagnosis. — Course. — Prognosis. — Mode of Infection. — 
Topography. — Central Osteosarcoma. — Periosteal Sarcoma. — Sarcoma of the Mam- 
ma, of the Salivary Glands. — 9. LympTiomata. — Anatomy.— Eelations to Leucaemia. 
— Treatment, p. 645 

LECTUEE XLIX. 

10. Papillomata. — 11. Adenomata. — 12. Cysts and Cystomata.— Follicular Cysts of the 

Skin and Mucous Membranes. — Neoplastic Cysts. — Cysts of the Thyroid Gland. — 
Ovarian Cysts. — Blood-Cysts, p. 666 

LECTUEE L. 

13 Carcinomata. — Historical Eemarks. — General Description of the Anatomical Struct- 
ure. — Metamorphoses. — Forms. — Topography. — 1. Skin and Mucous Membranes 
with Pavement Epithelium. — 2. Milk Glands. — 3. Mucous Glands with Cylindrical 
Epithelium. — i. Lachrymal Glands, Salivary Glands, and Prostate Glands. — 5. 
Thyroid Glands and Ovaries. — Treatment. — Brief Eemarks about the Diag- 
nosis, .p. 680 



CHAPTER XXI. 

AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 
LECTUEE LI. 

Importance of these Operations. — Amputations and Exarticulations. — Indications. — 
Methods. — After-Treatment. — Prognosis. — Conical Stumps. — Artificial Limbs. — 
History. — Eesection of the Joints. — History. — Indications. — Methods. — After- 
Treatment, p. 720 

Appendix: Additions from the Eighth German Edition, p. 739 

Index, P- 760 



LIST OF WOODCUTS. 



FIG. 

1. Diagram of connective tissue, with capillaries, . 

2. Diagram of incision, capillaries closed by blood-clots, collateral distention, 

3. Diagram representing the surface of the wound united by inflammatory new 

formation, . . . . 

3 a. Vessels from mesentery of frog, . 
3 b. Development of vessels, .... 
3 o. Vessels in vitreous body, .... 

4. Diagram of a wound with loss of substance, . 

5. Pus-cells from fresh pus, .... 

6. Diagram of granulation of a wound, 

7. Fatty degeneration of cells from granulations, . 
7 a. Epithelium of the cornea of a frog, 

8. Corneal incision three days old, 

9. Incised wound twenty-four hours old, . 

10. Cicatrix nine days after an incision, 

11. Granulation-tissue, ..... 

12. Young cicatricial tissue, .... 

13. Horizontal section through the tongue of a dog, 

14. Same, ten days old, ..... 

15. Same, sixteen days old, ..... 

16. Granulation- vessels, . . . 

17. Seven-days-old wound in the lip of a dog, 
17 a. Micrococcus, ..... 

18. Cicatrix from the upper lip of a dog, . 

19. Ends of divided muscular fibres, . 

20. Regenerative processes in transversely-striated muscle, 

21. Regeneration of nerves, .... 

22. " " 

22 a. Nerves after division, .... 

23. Nodular nerve-terminations in an old stump, 

24. Artery ligated in the continuity, . 

25. Transverse section of a fresh thrombus, 

26. Transverse section of thrombus six days old, 

27. Ten-days-old thrombus, ..... 

28. Completely-organized thrombus, . 

29. Longitudinal section of the ligated end of an artery, 

30. Portion of a transverse section of a vein, with organized thrombus 

31. Artery, injected six weeks after ligation, 

32. Artery, injected thirty-five months after ligation, 

33. Artery, injected three months after ligation, 

34. Artery wounded on the side, with clot, .... 



PAGE 

51 
52 



59 
60 
66 
67 
73 
75 
77 
78 
78 



83 

84 

84 

85 

86 

86 

87 

87 

103 

113 

114 

115 

116 

116 

117 

119 

120 

121 

122 

122 

123 

124 

125 

127 

127 

128 

135 



XV111 



LIST OF WOODCUTS. 



35. Aneurisma traumaticum, . . 

36. Varix aneurismaticus, ..... 

37. Aneurisina varicosum, ..... 

38. Granular and crystalline hsematoidin, 

39. Detachment of dead connective tissue in contused wounds 

40. Central end of a torn brachial artery, 

41. Evulsed middle finger, ..... 

42. Arm torn out, with scapula and clavicle, . 

43. Longitudinal section of a fracture four days old, 

44. Diagram of a longitudinal section of a fracture fifteen days old, 

45. Diagram of a longitudinal section of a fracture twenty -four weeks old 

46. Fracture, with dislocation, after twenty-seven days, 

47. Old united oblique fracture, .... 

48. Longitudinal section through the cortical substance, 

49. Inflammatory new formation in Haversian canals, 

50. Ossification of inflammatory neoplasia on the surface of the bone and in th 

Haversian canals, ..... 

51. Artificially-injected external callus, five days old, 

52. Artificially-injected transverse section, eight days old, 

53. Ossifying callus on the surface of a hollow bone, 

54. Detachment of a superficial piece of a flat bone, 

55. Detachment of a necrosed portion of bone, 

56. Fracture of a long bone with external wound, 

57. Necrosis of sawed surface of femur, 

58. Bullets of various styles, . . . 

59. Tiemann's bullet-forceps, .... 

60. Gunshot-fractures of femur and tibia, 

61. Traces of lightning, ..... 

62. Conjunctiva affected with catarrh, . 

63. Tissue from a prepuce infiltrated from inflammation, 

64. Purulent infiltration of the cutis connective tissue, 

65. Purulent infiltration of the cellular membrane, 

66. Vessels of the walls of an abscess, 
66 a. Growth of fungus from the cornea of a rabbit, 

67. Venous thrombus, ..... 

68. Fever curve after amputation of the arm, 

69. Fever curve after resection of carious wrist, 

70. Fever curve in erysipelas, .... 

71. Fever curve in septicaemia, .... 
71 a. Giant cells from tubercles in various stages, 
71 b. Minute tubercles in the peritoneum and on a cerebral artery 
71 c. Minute tubercles on a cerebral artery, 

72. Cutaneous ulcer of the leg, .... 

73. Granulations of a common ulcer, 

74. Caries superficial! s of the tibia, 

75. Section of a piece of carious bone, 
75 a. Ostitis malacissans, .... 

76. Disappearance of chalky salts from periphery of bone 

77. Sclerosed tibia and femur, .... 

78. Point of caseous degeneration in the spinal column, . 

79. Destruction of the vertebral column, 

80. Total necrosis of the diaphysis of a hollow bone, 

81. Total necrosis of the diaphysis of a hollow bone with detached sequestrum, 

82. Total necrosis of the diaphysis of a hollow bone after removal of sequestrum 



PAGE 

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137 
138 
147 
158 
183 
183 
183 
191 
191 
193 
194 
194 
195 
196 

198 
199 
199 
200 
217 
218 
219 
219 
256 
262 
264 
272 
288 
291 
292 
293 
294 
344 
359 
364 
365 
367 
371 
419 
420 
421 
435 
440 
451 
453 
459 
460 
460 
464 
466 
482 
484 
484 



LIST OF WOODCUTS. 



XIX 



S3. Total necrosis of the diaphy sis of the femur, . 

84. Total necrosis of the diaphysis of the tibia, 

85. Necrosis of the lower half of diaphysis of femur 

86. The body extracted from Fig. 85, 

87. Diagram of partial necrosis of a hollow bone, . 

88. Diagram of Fig. 87 in the later stages, 

89. Fig. 88, after removal of the sequestrum, 

90. Scapula of a dog, resected with and without periosteum 

91. Eachitic malformations of the leg, 

92. "Woman with extensive osteomalacia, 

93. Section of knee-joint with fungous inflammation, 

94. Degeneration of cartilage in fungous inflammation 

95. Subchondral caries of the astragalus, 

96. Atonic ulceration of cartilage from the knee-joint, 

97. Diagram of the ordinary ganglion, 

98. Hernial protrusions of synovial membrane, 

99. Degeneration of the cartilage in arthritis deforman 

100. Osteophytes in arthritis deformans, 

101. Fungous inflammation of the elbow-joint, 

102. Osteophytes in arthritis deformans, 

103. Multiple articular bodies, 

104. Band-like adhesions in a resected elbow-joint, 

105. Adhesion of articular surfaces of the elbow-joint, 

106. Elbow-joint anchylosed by bony bridges, . 

107. Section of the shoulder-joint, 

108. Section of the shoulder-joint, 

109. Contraction of the fascia lata, 

110. Cicatricial contractions after burns 

111. Cicatricial contractions after burns 

112. Subcutaneously-divided tendon, 

113. Varices, .... 

114. Cirsoid aneurism of the scalp, 

115. Small fibroma, 

116. From a myo-fibroma, . 

117. Vessels from a cutis fibroma, 

118. Neuroma, 

119. Fibro-sarcomatous neuromata, 

120. Cartilage tissue from chondromata, 

121. Chondroma of the fingers, 

122. Odontoma of a back tooth, 

123. Section of an odontoma, . 

124. Pedunculated spongy exostosis, 

125. Ivory exostosis of the skull, 

126. Section from an ivory osteoma, 

127. Osteoma of the muscular attachments 

128. Vessels from a plexiform angioma, 

129. Mesh-work from a cavernous angioma 

130. Tissue of granulation-sarcoma, 

131. Tissue of glio-sarcoma, . 

132. Tissue of a spindle-celled sarcoma, 

133. Giant-cells from a sarcoma, 

134. Giant-celled sarcoma with cysts, 

135. Cell-globules from a sarcoma, . 

136. Mucous tissue from a myxosarcoma, 



PAGE 

485 

485 

486 

487 

487 

488 

488 

489 

496 

501 

506 

508 

509 

512 

528 

531 

535 

537 

537 

537 

543 

547 

548 

548 

549 

549 

565 

566 

566 

570 

577 

582 

619 

620 

621 

622 

622 

628 

630 

632 

632 

633 

634 

634 

635 

639 

640 

646 

646 

647 

648 

648 

649 

649 



XX 



LIST OF WOODCUTS. 



FIG. 

137. Mucous tissue from an adenomyxoma, 

138. Alveolar sarcoma from the deltoid muscle, . 

139. Alveolar sarcoma from the tibia, 

140. Central osteosarcoma of the ulna, 

141. Section of Fig. 140, ..... 

142. Central osteosarcoma of the lower jaw, 

143. Section of Fig. 142, 

144. Compound cystoma of the thigh, 

145. Periosteal sarcoma of the tibia, .... 

146. Section of Fig. 145, 

147. From an adeno-sarcoma of the female breast, . 

148. From the cortical layer of a hyperplastic lymphatic gland 

149. Sections of a wart, ..... 

150. From a mucous polypus, .... 

151. Adenoma of the thyroid, . . . 

152. Commencing epithelial cancer of the lip, 

153. Flat epithelial cancer of the cheeks, 

154. Elements of an epithelial carcinoma of the lip, 

155. From an epithelial cancer of the hand, . 

156. Vessels from a carcinoma of the penis, 

157. Papillary formation of a villous cancer, . 

158. Mammary cancer, acinous form, 

159. Soft mammary cancer, ..... 

160. From a mammary cancer, .... 

161. Connective-tissue frame-work of a cancer of breast, 

162. Cancer of breast, tubular form, 

163. Cancer of the mamma from an atrophied part, . 

164. Vascular net-work from a very young nodule, 

165. Vascular net-work around points of softening, . 

166. Connective-tissue infiltration, etc., . 

167. Cellular infiltration of fatty tissue, etc., 

168. Cancer of the mucous glands from nose, 

169. Adenoid cancer of the rectum, . 
139 a. Villous sarcoma, 
139 b. Psammona, . . • 
139 c. From a cerebral tumor, 
139 d. Plexiform sarcoma, 
139 e. From a cylindroma of the orbit, . 



PAGE 

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651 

651 
655 
655 
656 
656 
657 
658 
658 
660 
663 
667 
670 
672 
686 
686 
687 



693 
696 



697 



699 
700 
701 
705 
706 
708 
709 
752 
754 
755 
755 
756 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



LECTURE I, 

INTRODUCTION. 



Relation of Surgery to Internal Medicine.— Necessity of the Practising Physician 
being acquainted with both. — Historical Eemarks. — Nature of the Study of Sur- 
gery in the German High-schools. 

Gentlemen : The study of surgery, which you begin with this 
lecture, is now, in most countries, justly regarded as a necessity for 
the practising physician. We consider it a happy advance that the 
division of surgery from medicine no longer exists, as it did formerly. 
The difference between internal medicine and surgery is in fact only 
apparent ; the distinction is artificial, founded though it be on history, 
and on the large and increasing literature of general medicine. In 
the course of this work your attention will often be called to the 
frequency with which surgery must consider the general state of the 
body, to the analogy between the diseases of the external and inter- 
nal parts, and to the fact that the whole difference depends on our 
seeing before us the changes of tissue that occur in surgical diseases, 
while we have to determine the affections of internal organs from the 
symptoms. The action of the local disturbances on the body at large 
must be understood by the surgeon, as well as by any one who pays 
especial attention to diseases of the internal organs. In short, the 
surgeon can only judge safely and correctly of the state of his patient 
when he is at the same time a physician. Moreover, the physician who 
proposes refusing to treat surgical patients, and to attend solely to the 
treatment of internal diseases, must have some surgical knowledge, or 
he will make the grossest blunders. Apart from the fact that the 
country physician does not always have a colleague at hand to whom 
he can turn over his surgical patients, the life of the patient often de- 
pends on the correct and instantaneous recognition of a surgical disease. 
1 



2 INTRODUCTION 

When blood spouts forcibly from a wound, or a foreign body has 
entered the windpipe, and the patient is threatened with suffocation, 
then surgical aid is required, and quickly too, or the patient dies. In 
other cases, also, the physician ignorant of surgery may do much harm 
by not recognizing the importance of a case ; he may allow a disease 
to become incurable, and by his deficient knowledge cause unspeakable 
injury, in a case which might have been relieved by early surgical 
treatment. Hence it is inexcusable for a physician obstinately to 
stick to the idea of only practising internal medicine ; still more inex- 
cusable is it, in this idea, to neglect the study of surgery : " I will not 
operate, because in ordinary practice there is so little operating to be 
done, and I am not at all suited for an operator ! " As if surgery con- 
sisted only in operations. I hope to give you a better idea of this 
branch of medicine than is conveyed by the above remark, which un- 
fortunately is too popular. 

From the fact that surgery has to deal chiefly with patent dis- 
eases, it certainly has an easier position in regard to anatomical diag- 
nosis ; but do not regard this advantage too highly. Besides the fact 
that surgical diseases also often lie deeply hidden, more is demanded 
from a surgical diagnosis and prognosis, and even in the treatment, than 
from the therapeutic action of internal medicine. I do not deny that 
in many respects internal medicine may hold a higher rank, just on 
account of the difficulties it has (and often so brilliantly overcomes) 
in localizing and recognizing disease. Very fine operation of the mind 
is often necessary to come to a proper conclusion, from the combination 
of symptoms, and the results of the examination. Physicians may 
point with pride to the anatomical diagnosis of diseases of the heart and 
lungs, where the careful student succeeds in giving as accurate a de- 
scription of the changes in the diseased organ as if he had it right 
under his eyes. How wonderful it is to gain an accurate knowledge 
of the morbid state of hidden organs, such as the kidneys, liver, 
spleen, intestines, brain, and spinal marrow, by the examination of a 
patient and the combination of symptoms ! What a triumph to diag- 
nose diseases of organs of which we do not know even the physiolo- 
gical function, as of the supra-renal capsules ! This is some compensa- 
tion for the fact that, in internal medicine, we must more frequently 
acknowledge the impotence of our treatment than is the case in 
surgery, although, from the advances in anatomical diagnosis, we have 
become more certain of what we can do, and of what we cannot. 

The irritation of the finer, cultivated portions of the mind in inter- 
nal medicine is, however, richly balanced by the greater certainty and 
clearness of diagnosis and treatment in surgery, so that the two 
branches of medical science are exactly on a par. And it must not 



INTRODUCTION. 3 

be forgotten that the anatomical diagnosis — I mean the recognition of 
the pathological changes in the diseased organ — is only one means to 
the end, which is the cure of the disease. The true problems for the 
physician are to find out the causes of the morbid process, to prog- 
nosticate the course, conduct it to a favorable termination, or control 
it, and these are equally difficult in internal and external medicine. 
Only one thing more is required of the practical surgeon : this is, the 
art of operating. This, like every art, has its knack ; the facility of 
operating secondarily depends on accurate knowledge of anatomy, on 
practice, and on personal aptitude. This aptitude may also be culti- 
vated by persevering practice. Just remember how Demosthenes suc- 
ceeded in acquiring fluency in speaking. 

This knack, which is certainly necessary, has long separated sur- 
gery from medicine in the strict sense ; we may historically follow 
this separation as it constantly became more practically felt, till in 
this century it was finally recognized as impractical and was abol- 
ished. The word " chirurgery " at once expresses that originally it 
was regarded as entirely manual, for it comes from x EL ? an d Zpyov, 
which literally mean " hand-work," or, in the pleonasm of the middle 
ages, " hand-work of chirurgery." 

Little as it comes within the scope of this work to give a complete 
sketch of the history of surgery, it still seems to me important and in- 
teresting to give you a short sketch of the external and internal de- 
velopment of our science, which will explain to you some of the va- 
rious regulations affecting the so-called "medical staff" still existing in 
different states. A fuller history of surgery can only be of use to you 
hereafter, when you shall have acquired some knowledge of the value 
or worthlessness of certain systems, methods, and operations. Then, 
in the historical development of the science, especially as regards op- 
erative surgery, you will find the key for some surprising and for 
some isolated experience, also for much that is incomplete. Many 
things that may be necessary for the comprehension of the subjects, I 
shall relate to you when speaking of the different diseases ; now, I 
shall only present a few prominent points in the development of sur- 
gery and of its present position. 

Among the people in former times, the art of healing was inti- 
mately associated with religious education. The Hindoos, Arabs, and 
Egyptians, as well as the Greeks, considered the art of healing as a 
manifestation made by the gods to the priests, and then spread by tradi- 
tion. Philologists were not agreed as to the age of the Sanscrit writ- 
ings discovered not long since ; formerly their origin was placed at 
1000-1400 B. c, now it is considered certain that they were written 
in the first century of the Christian era. The Agur-Veda (" Book of 



4 INTRODUCTION. 

the Art of Life ") is the most important Sanscrit work for medicine ; it 
is the production of Smrutas. It very probably originated in the time 
of the Roman Emperor Augustus. The art of healing was regarded 
as a whole, as is indicated by the following: " It is only the combina- 
tion of medicine and surgery that makes the complete physician. The 
physician lacking knowledge of one of these branches is like a bird 
with only one wing." At that time surgery was without doubt by 
far the more advanced part of the medical art. A large number of op- 
erations and instruments are spoken of; still, it is truly said " the best 
of all instruments is the hand ; " the treatment of wounds given is 
simple and proper. Most surgical injuries were already known. 

Among the Greeks all medical knowledge at first centred in^7s- 
culapius, a son of Apollo, and a scholar of the Centaur Chiron. 
Many temples were built to iEsculapius, and the art of healing was 
handed down by tradition through the priests of these temples ; the 
number of these temples induced various schools of JEsculapides, and, 
although every one entering the temple as a priest had to take an 
oath, which has been handed down to our own times (although of late 
its genuineness appears rather doubtful), that he would only teach 
the art of healing to his successors, still, as appears from various cir- 
cumstances, even at that time there were other physicians besides the 
priests. From one part of the oath, even, it is evident that then as now 
there were physicians who, as specialists, confined themselves to cer- 
tain operations ; for it says : " Furthermore, I will never cut for stone, 
but will leave this operation to men of that occupation." Of the 
different varieties of physicians we know nothing more accurate till 
the time of Hippocrates ; he was one of the last of the Asklepiades. 
He was born 460 b. c, oh the island of Cos ; lived partly in Athens, 
partly in Thessalian towns, and died 377 b. c. at Larissa. "We might 
expect that medicine would be considered scientifically at this time, 
when the names of Pythagoras, Plato, and Aristotle, were shining in 
Grecian science ; and in fact the works of Hippocrates, many of which 
are still preserved, arouse our astonishment. The clear classical de- 
scription, the arrangement of the whole material, the high regard for 
the healing art, the sharp critical observations, that appear in the 
works of Hippocrates, and compel our admiration and respect for an- 
cient Greece on this branch also, clearly show that it is not a case of 
blind belief in traditional medical dogmas, but that there was already 
a scientific and elaborately perfected medicine. In the Hippocratic 
schools the art of healing formed one whole ; medicine and surgery 
were united, but there were various classes of medical practitioners ; 
besides the Asklepiades there were other educated physicians, as well 
as more mechanically instructed medical assistants, gymnasts, quacks, 



INTRODUCTION. 5 

and workers of miracles. The physicians took scholars to train in the 
art of healing ; and, according to some remarks of Xenophon, there 
were also special army physicians ; especially in the Persian wars, 
they, together with the soothsayers and flute-players, had their places 
near the royal tent. It may be readily understood that, at a time 
when so much was thought of corporeal beauty, as was the case 
among the Greeks, external injuries would claim special attention. 
Hence, among physicians of the Hippocratic era, fractures and sprains 
were particularly studied ; still, some severe operations are treated of, 
as also numbers of instruments and other apparatuses. They seem to 
have been very backward regarding amputations ; probably the 
Greeks preferred dying to prolonging life after they were mutilated. 
The limb was only removed when it was actually dead, gangrenous. 

The teachings of Hippocrates could not at first be carried any fur- 
ther, for lack of knowledge of anatomy and physiology. It is true 
there was a faint effort made in this direction in the scientific schools 
of Alexandria, which flourished for some centuries under the Ptole- 
mies, and by means of which, after the wars of Alexander the Great, 
the Grecian spirit was spread, at least temporarily, over part of the 
Orient ; but the Alexandrian physicians soon lost themselves in phil- 
osophical systems, and only advanced the science of healing a little 
by a few anatomical discoveries. In this school the art of healing 
was at first divided into three separate parts — dietetics, internal medi- 
cine, and surgery. Along with Grecian culture, their knowledge of 
medicine was also brought to Rome. The first Roman physicians were 
Grecian slaves ; the freedmen among them were allowed to erect 
baths ; here, first, barbers and bathers became our rivals and col- 
leagues, and for a long time they injured the respectability of the pro- 
fession in Rome. Gradually the philosophically-minded took posses- 
sion of the writings of Hippocrates and the Alexandrians, and them- 
selves practised medicine, without, however, adding to it much that was 
new. The great lack of original scientific production is shown in the 
encyclopedial revision of the most varied scientific works. The most 
celebrated work of this nature is the " De Artibus " of Aulus Corne- 
lius Gelsus (from 25-30 b. c. to 45-50 a. d., in the time of the Em- 
perors Tiberius and Claudius). Eight books of this, " De Medicina" 
have come down to our time ; from these we know the state of medi- 
cine and surgery at that time. Valuable as are these relics from the 
Roman ages, they are only, as we have said, a compendium, such as 
is often published at the present day. It has even been denied that 
Celsus was a practising physician, but this is improbable ; from his 
writings we must, at all events, credit Celsus with using his own judg- 
ment. The seventh and eighth books, which treat on surgery, could not 



6 INTRODUCTION. 

have been written so clearly by any one who had no practical knowl- 
edge of his subject. Hence we see that, since the time of Hippo 
crates and the Alexandria school, surgery, especially the operative 
part, had made no great progress. Celsus speaks of plastic opera- 
tions, of hernia, and gives a method of amputation which is still occa- 
sionally employed. One part, from the seventh book, where he speaks 
of the qualifications of the perfect surgeon, is quite celebrated, as it 
is characteristic of the spirit which reigns in the book ; I give it to 
you : " The surgeon should be young, or at least little advanced in 
age, with a hand nimble, firm, and never trembling ; equally dexter- 
ous with both hands ; vision, sharp and distinct ; bold, unmerciful, so 
that, as he wishes to cure his patient, he may not be moved by his 
cries to hasten too much, or to cut less than is necessary. In the 
same way let him do every thing as if he were not affected by the 
cries of the patient." 

Claudius Galenus (131-201 a. d.) must be regarded as a phe- 
nomenon among the Roman physicians; eighty-three undoubtedly 
genuine medical writings of his have come down to us. Galen re- 
turned again to the Hippocratic belief, that observation must form 
the foundation of the art of healing, and he advanced anatomy great- 
ly; he made dissections chiefly of asses, rarely of human beings. 
Galen's anatomy, as well as the entire philosophical system into 
which he brought medicine, and which seemed to him even more im- 
portant than observation itself, has stood firm over a thousand years. 
He occupies a very prominent position in the history of medicine. He 
did little for surgery in particular ; indeed, he practised it little, for in 
his time there were special surgeons, either gymnasts, bathers, or 
barbers, and so unfortunately surgery was handed down by tradition 
as a mechanical art, while internal medicine was, and long remained, 
in the hands of philosophic physicians; the latter knew and com- 
mented freely on the surgical writings of Hippocrates, the Alexandri- 
ans, and Celsus, still they paid little attention to surgical practice. 
As we are only giving a faint sketch, we might here skip several cen- 
turies, or even a thousand years, during which surgery made scarcely 
any progress, indeed retrograded occasionally. The Byzantine era of 
the empire was particularly unfavorable to the advance of science, 
there was only a short flickering up of the Alexandria school. Even 
the most celebrated physicians of the later Roman times, Antyllus (in 
the third century), Oribasius (326-403 a. d.), Alexander of Tralles 
(525-605 A. d.), Paulus of ^Jgina (660), did relatively little for sur- 
gery. Some advance had been made in the position and scholarly at- 
tainments of physicians ; under Nero there was a gymnasium ; under 
Hadrian an athenaeum, scientific institutions where medicine also was 



INTRODUCTION. 7 

taught; under Trajan, there was a special medical school. Military 
medical service was attended to among the Romans, and there were 
special court physicians, " archiatri palatini," with the title of " per- 
fectissime," " eques," or * comes archiatrorum," just as, among the 
Germans, " Hofrathe," " Geheimrathe," " Leibarzte," etc. That, as a 
result of the fall of science in the Byzantine reign, the art of healing 
did not totally degenerate, is due to the Arabians. The wonderful 
elevation that this people attained under Mohammed, after the year 
608, aided in preserving science. The Hippocratic knowledge of 
medicine, with the later additions to it, passed to the Arabians 
through the Alexandrian school, and its branches in the Orient, the 
schools of the Nestorians ; they cherished it till their power was de- 
molished by Charles Martel, and returned it to Europe by way of 
Spain, though somewhat changed in form. Ithazes (850-932), Avi- 
cenna (980-1037), Alhucasis (f 1106), and Avenzoar (f 1162), are the 
most celebrated, and for surgery the most important, of the Arabian 
physicians whose writings have been preserved ; the writings of the 
latter are the most important for surgery. Operative surgery suffered 
greatly from the dread the Arabians had of blood, which was partly 
due to the laws of the Koran ; it caused the employment of the ac- 
tual cautery to an extent that we can hardly comprehend. The dis- 
tinction of surgical diseases and the certainty of diagnosis had de- 
cidedly increased. Scientific institutions were much cultivated by the 
Arabians ; the most celebrated was the school of Cordova ; there were 
also hospitals in many places. The study of medicine was no longer 
chiefly private, but most of the students had to complete their 
studies at some scientific institution. This also had its effect on the 
nations of the West. Besides Spain, Italy was the chief place where the 
sciences were cultivated. In southern Italy there was a very cele- 
brated medical school at Salerno / it was probably founded in 802 
by Charles the Great, and was at its zenith in the twelfth century ; 
according to the most recent ideas, this was not an ecclesiastical 
school, but all the pupils were of the laity. There were also female pu- 
pils, who were of a literary turn ; the best known among these was 
Trotula. Original observations were not made there, or at least to a 
very slight extent, but the writings of the ancients were adhered to. 
This school is also interesting from the fact that it is the first cor- 
poration that we find having the right to bestow the titles " doctor " 
and " magister." 

Emperors and kings gradually took more interest in science, and 
founded universities; thus universities were founded in Naples in 
1224, in Pavia and Padua in 1250, in Paris in 1205, in Salamanca in 
1243, in Prague in 1348, and they were invested with the right of 



3 INTRODUCTION. 

conferring academical honors. Philosophy was the science to which 
most attention was paid, and for a long time Medicine preserved her 
philosophical robe in the universities ; in some cases they adhered to 
Galen's system, in others to the Arabian or to new medico-philo- 
sophical systems, and registered all their observations under these 
heads. This was the great obstacle to the progress of the natural 
sciences, a mental slavery, from which even men of intellect could not 
free themselves. The anatomy of Mondino de Imzzi (1314) differs 
very little from that of Galen, in spite of the fact that the author 
bases it on dissections he made of some human bodies. In surgery 
there were no actual advances ; Lanfranchi (f 1300), Guido of Gauli- 
aco (beginning of the fourteenth century), Branca (middle of the 
fifteenth century), are a few of the noteworthy surgeons of those times. 
Before passing to the flourishing state of the natural sciences and of 
medicine in the sixteenth century, we must review briefly the composi- 
tion of the medical profession in the times of which we have been 
speaking, as this is important for the history. First, there were philo- 
sophically educated physicians either lay or monk, who had learned 
medicine in the universities or other schools ; i. e., they had studied 
the old writings on anatomy, surgery, and special medicine ; they prac- 
tised, but paid little attention to surgery. Another seat of learning 
was in the cloisters ; the Benedictines especially paid a great deal of 
attention to medicine and also practised surgery, although the supe- 
riors disliked to see this, and occasionally special dispensation had to 
be obtained for an operation. The regular practising physicians were 
sometimes located, sometimes travelling. The former were usually 
educated at scientific schools and received permission to practise on 
certain conditions. In 1229, the emperor Frederick II. published a 
law that these physicians should study logic (that is, philosophy and 
philology) three years, then medicine and surgery five years, and then 
practise for some time under an older physician; before receiving 
permission to practise independently, or, as an examiner lately said, 
of physicians who had just received their degree, " till they were let 
loose on the public." Besides these located physicians, of whom a 
great part were " doctor " or " magister," there were many " travelling 
doctors," a sort of " travelling student " who went through the market- 
towns in a wagon with a merry Andrew, and practised solely for 
money. This genus of the so-called charlatans, which played an im 
portant part in the poetry of the middle ages, and is still gleefully 
greeted on the stage by the public, carried on a rascally trade in the 
middle ages ; they were as infamous as pipers, jugglers, or hangmen ; 
even now these travelling scholars are not all dead ; although, in the 
nineteenth century, they do not ply their trade in the market-place, but 



INTRODUCTION. 9 

ji the drawing-rooms as workers of miracles, especially as cancer-doc- 
tors, herb-doctors, somnambulists, etc. Let us now inquire the rela- 
tion, of those who practised surgery, to the above company. This 
branch of medicine was occasionally resorted to by almost all of the 
above ; still there were special surgeons, who united into guilds and 
formed honorable societies ; they received their practical knowledge 
first from a master, under whom they studied, and subsequently from 
books and scientific institutions. Surgical practice was chiefly confined 
to these persons, who were mostly located, but sometimes travelled 
about as " hernia doctors," " operators for stone," " oculists," etc. "We 
shall become acquainted with some excellent men among these old mas- 
ters of our art. Besides the above, surgery was also practised by the 
" bathers," and later by " barbers " also, as it was among the Romans, 
and they were permitted by law to attend to " minor surgery," e. g., 
they could cup, bleed, treat fractures, sprains, etc. It will be readily 
understood that some strife would arise about the various and some- 
times indefinite privileges of these different grades of physicians, 
especially in large cities, where all classes of them were collected. 
This was particularly the case in Paris. The surgical society there, 
the " College de St. Come," claimed the same privileges as members 
of the medical faculty ; they were particularly desirous for the Bacca- 
laureate and Licentiate. The " Society of Barbers and Bathers," 
again, wished to practise any part of surgery, just like the members of 
the College de St. Come. To gall the surgeons, the members of the fac- 
ulty supported the claims of the barbers, and, in spite of mutual tempo- 
rary compromises, the strife continued ; indeed, we may say that it still 
continues, where there are pure surgeons (surgeons of the first class 
and barbers) and pure physicians. It is only since about 1850 that 
the distinction was done away with in almost all the German states, 
and neither chirurgi puri nor medici puri were made, but only physi- 
cians who practised medicine, surgery, and obstetrics. 

To finish the question of external rank, we may notice that in Eng- 
land alone there is still a tolerably well-marked dividing-line be- 
tween surgeons and physicians, especially in the cities, while in the 
country " general practitioners " attend to both medical and surgical 
cases, and have an apothecary-shop even at the same time. 

In Germany, Switzerland, and France, circumstances often cause a 
physician to have more surgical than medical practice ; but the med- 
ical staff legally consists of physicians and assistants or barber-sur- 
geons, who, after examination, are licensed to cup, bleed, etc. This 
arrangement has finally gone into effect in the army also, where the 
so-called company surgeon, with the rank of sergeant, formerly had a 
miserable time under the battalion and regimental physicians. 



10 INTRODUCTION. 

In again taking up the thread of the historical development of 
surgery, as we enter the period of " Renaissance " in the sixteenth 
century, we must first think of the great change which then took place 
in almost all sciences and arts, on account of the Reformation, the 
discovery of printing, and the awakening spirit of criticism. Obser- 
vation of Nature began to reassume its proper position and gradually 
but slowly to free itself from the fetters of the schools ; investigation 
after truth again assumed its claims to being the only true way to 
knowledge — the Hippocratic spirit was again awakened. It was 
chiefly the new investigations, we might almost say the rediscovery, 
of anatomy and the subsequent restless progress of this branch, that 
levelled the road. Vesal (1513-1564), Miopia (1523-1562), and Fus- 
tachio (f 1579), were the founders of our present anatomy ; their names, 
like those of many others, are known to you from the appellations of 
certain parts of the body. The celebrated Bombastus Theophrastus 
Paracelsus (1493-1554) was among the first to criticise the prevailing 
Galenical and Arabic systems, and to claim observation as the chief 
source of medical knowledge. Finally, when William Savvey 
(1578-1658) discovered the circulation of the blood, and Aselli (1581- 
1626) discovered the lymphatic vessels, the old anatomy and physiol- 
ogy were obliged to give place to modern science, which thence grad- 
ually progressed to our times. Even then it was a long time before 
practical medicine escaped in the same way from philosophic thral- 
dom. System was founded on system, and the theory of medicine 
constantly varied to correspond to the prevailing philosophy. We may 
claim that it was not till pathological anatomy made its great ad- 
vances in the present century that practical medicine acquired the 
firm anatomico-physiological foundation on which the whole structure 
now moves, and which forms a strong protection against all philosoph- 
ical medical systems. Even this anatomical direction, however, may be 
pushed too far and too exclusively. "We shall speak of this hereafter 

Now we will turn our attention to the scientific development of 
surgery from the sixteenth century to our times. 

It is an interesting feature of that time that the advance of practi- 
cal surgery depended more on the surgical societies than on the 
learned professors of the universities. German surgeons had to seek 
their knowledge mostly in foreign universities, but part of it they 
worked out for themselves independently : Heinrich von JPfolspru?idt, 
a German friar (born the beginning of the fifteenth century), Hieron- 
ymus Brunschwig (born 1430), Hans von Gersdorf (about 1520), and 
Felix Wiirtz (fl576), surgeons at Basel, are first among these. We 
have writings of all of them ; Felix WlXrtz seems to me the most 
original of them ; he had a sharp, critical mind. Fabry von Hilden 



INTRODUCTION. 11 

(1560-1634), of Berne, and Gottfried Purman, of Halberstad and 
Breslau (about 1679), were men of great acquirements ; their writ- 
ings show a high appreciation for their science, they fully recognized 
the value and imperative necessity of exact anatomical knowledge, 
and by their writings and private instruction imparted it to their 
scholars as much as possible. 

Among the French surgeons of the sixteenth and seventeenth cen- 
turies, Ambroise Pare (1517-1590) is most prominent ; originally only 
a barber, from his great services, he was made a member of the So- 
ciety of St. C6me; he was very active as an army surgeon, was often 
called from home on consultations, and at last resided in Paris. Par'e 
advanced surgery by what was for those times a very sharp criticism 
of treatment, especially of the enormous use of problematical remedies ; 
some of his treatises, e. g., on the treatment of gun-shot wounds, are 
perfectly classical; he rendered himself immortal by the introduction of 
ligature for bleeding vessels after amputation. Pare, as the reformer 
of surgery, may be placed by the side of Vesal, as reformer of anatomy. 

The works of the above individuals, besides some others more or 
less gifted, held their place into the seventeenth century, and it is 
only in the eighteenth that we find any important advances. The 
strife between the members of the faculty and those of the College 
de St. Come still continued in Paris ; the great celebrity of the latter 
had more effect than the professors of surgery. This was finally prac- 
tically acknowledged in 1731 by the foundation of an "Academy of 
Surgery," which was in all respects an analogue of the medical faculty. 
This institution soon advanced to such a point that it ruled the sur- 
gery of Europe almost a century ; nor was this an isolated cause ; it 
formed part of the general French influence, of that universal mental 
dominion which the " grande nation " cannot even yet forget when 
German science has forever eclipsed French influence, after the con- 
flicts of 1813-'14. The men who then stood at the head of the 
movement in surgical science were Jean Louis Petit (1674-1768), 
Pierre Jos. Desault (1744-1795), Pierre Francois Percy (1754- 
1825), and many others in France; in Italy, Scarpa (1748-1832) was 
the most active. Even in the seventeenth century, surgery was highly 
developed in England, and in the eighteenth century it attained great 
eminence under Percival Pott (1713-1768), William and John 
Hunter (1728-1793), Benjamin Bell (1749-1806), William Chesel- 
den (1688-1752), Alexander Monro (1696-1767), and others. 
Among these was John Hunter, that great genius, as celebrated 
for anatomy as surgery; his work on inflammation and wounds 
still forms the basis of many of our present views. 

In comparison with these, the names of the German surgeons of 



12 INTRODUCTION. 

the eighteenth century are insignificant ; most of them brought theii 
knowledge from Paris, and added little that was original : Lorenz 
Seister (1683-1758), John Ulrich Bilguer (1720-1796), and Chr. 
Ant. Theden (1719-1797), are relatively the most important. Ger- 
man surgery only obtained greater eminence with the commencement 
of the present century. Carl Caspar von Siebold (1736-1807), and 
August Gottlob Bichter (1742-1812), were distinguished men ; the 
former served as professor of surgery in Wurzburg, the latter in Got- 
tingen ; some of Hichter' s writings are valuable even now, especially 
his little book on rupture. 

On the threshold of our century you see professors of surgery 
again in the foreground, where they subsequently maintained their 
position, because they aciaially practised surgery. A predecessor of 
old Bichter, as professor of surgery at Gottingen, the celebrated Al- 
bert Sailer (1708-1777), at once physiologist and poet, one of the last 
encyclopaedists, says, " Etsi chirurgiae cathedra per septemdecim an- 
nos mihi concredita fuit, etsi in cadaveribus dificilimas administrationes 
chirurgicas frequenter ostendi, non tamen unquam vivum hominem 
incidere sustinui, nimis ne nocerem veritus." To us this seems 
scarcely Credible, so great is the change wrought by a hundred years. 
Even at the commencement of this century the French surgeons re- 
mained at the helm ; Boyer (1757-1833), Delpech (1776-1832), and par- 
ticularly Dupuytren (1777-1835), and Jean Dominique Larrey (1776- 
1842), were almost undisputed authorities in their line. Besides them 
there arose in England the unimpeachable authority, Sir Astley Coop- 
er (1768-1841). Larrey ', the constant companion of Napoleon I., left a 
large number of works ; you will hereafter read his memoirs with 
great interest. Dupuytren was chiefly celebrated for his excellent 
clinical lectures. Cooper's monographs and lectures will fill you with 
astonishment. Translations of the writings of the above French and 
English surgeons first aroused German surgery ; but soon the subject 
was gone into most profoundly by original workers. The men who 
induced the German revolution in surgery were, among others, Vincenz 
von Kern, of Vienna (1760-1829), John JSTep. Bust, of Berlin (1775- 
1840), Philipp von Walther, of Munich (1782-1849), Carl Ferd. von 
Graefe, of Berlin (1787-1840), Conr. Joh. Martin Langenbeck, of 
GQttingen (1776-1850), Joh. Friedrich Dieffenbach (1795-1847), 
Cajetan von Textor (1782-1860), of Wurzburg. 

The nearer we approach the middle of our century, the more the 
rugged bounds of nationality disappear from the domains of surgery. 
With increased means of communication, all advances in science 
spread with breathless haste to all parts of the civilized world. Num- 
berless writings, national and international medical congresses, and 



INTRODUCTION. 13 

personal intercourse, have brought radical changes to the surgeons as 
well as to others. A generation of surgeons, upon whose works 
the profession looks with honor, appears to be now dying out; I 
mean men such as Stanley (1791-1862), Lawrence (1783-1867), and 
Brodie (1783-1862), in England; JRoux (1780-1854), Bonnet (1809- 
1858), Leroy (1798-1861), Malgaigne (1806-1865), Civiale (fl867), 
Jobert (1799-1868), and Velpeau (1795-1867), in France; Seutin 
(1793-1862), in Belgium ; Valentine Mott (1785-1865), in America; 
Wutzer (1789-1863), Schuh (1804-1865), and others, in Germany. 
From our own generation also we have some losses to mourn, espe- 
cially the irreparable death of the gifted, indefatigable investigator 
O. Weber (1827-1867) ; of the excellent Follin (-1867), one of the 
most solid of modern French surgeons ; of Middeldorpf (1824-1868), 
the celebrated inventor of galvano-caustic operations. Among the 
living we might name many on whose shoulders rests the growing 
generation of German surgeons, but they do not yet belong to his- 
tory. But there is one point I must not leave unmentioned, that is, the 
introduction of pain-quelling remedies into surgery. The nineteenth 
century may be proud of the discovery of the practical use of sulphu- 
ric ether and chloroform as anaesthetics in all sorts of operations. In 
1846 came from Boston the first news that Morton the dentist, at the 
suggestion of his friend Br. Jackson, had, in extracting teeth, em- 
ployed inhalations of sulphuric ether, pushed to complete anaesthesia, 
with perfect success. In 1859, Simpson, professor of obstetrics in Ed- 
inburgh, instead of ether, introduced in surgical practice chloroform, 
which acts still better, which, after various trials with other similar 
substances, still preserves its reputation. Thanks ! in the name of 
suffering humanity, a thousand thanks to these men ! 

In continuation of my previous remarks regarding German sur- 
gery, I will simply add that at present it stands at least equal to that 
of other nations, and is perhaps even superior to that of France at the 
present time. To perfect ourselves in the science of surgery, we no 
longer need to visit Paris. But, of course, it is nevertheless desirable 
for every physician to enlarge his experience and observation by visit- 
ing foreign lands. In the scientific as well as in the practical part of 
surgery, and of medicine generally, England is now more advanced 
than any other country. In America also great advances have been 
made in practical surgery. From the time of Hunter to the present 
day, English surgery has about it something noble. Surgery owes 
its great revolution in the nineteenth century to its attempt to unite 
all medical knowledge in itself ; the surgeon who succeeds in this, and 
also masters the entire mechanical side of the art, may feel that he 
has attained the highest ideal in medicine. 



14 INTRODUCTION. 

Before entering on our subject, I will add a few remarks about 
the study of surgery as it is, or is said to be, pursued in our high- 
schools. 

In the four years' course of medical study which is customary in 
German universities, I would advise you not to begin surgery before 
the fifth semestre. You often desire to escape the preliminary studies 
and plunge at once into the practical. It is true, this is somewhat 
less the case since courses on anatomy, microscopy, physiology, chem- 
istry, etc., have been started in the high-schools, where you have some 
practice ; nevertheless, there is still too much haste to enter the clin 
ics. It is true, it is one way of gaining experience from the very start ; 
you consider it more interesting than bothering yourselves at first 
with things whose connection with practice you do not exactly un- 
derstand. But you forget that a certain school of observation must 
be gone through with, to enable us to make actually useful what we 
know. If any one just released from school should at once enter 
the hospital as a student, he would be in the same position as a child 
entering the world to collect knowledge. Of what use are the ex- 
periences of the child for his subsequent life among men ? How late 
it is before we see the true use of the most common observations of 
daily life ! Hence, to wade through the entire development of medi- 
cine in this empirical manner would be a long, tedious labor, and only 
a very gifted, industrious man would learn any thing in this way. 
After having made numerous errors, we must not place too great a 
value on " experience " and " observation," if by these terms we mean 
no more than the laity do. It is an art, a talent, a science, to observe 
critically, and from our observations to draw correct conclusions for 
our " experience ; " this is the strong point of the empiric ; the laity 
know experience and observation in the vulgar, not in the scientific 
sense, and they value the so-called experience of an old shepherd as 
high as, sometimes higher than, that of a physician ; unfortunately, 
the public are sometimes right on this point. But enough ! when a 
physician or any one else displays his experience and observation be- 
fore you, look sharply to see whether he has any brains. 

In making these remarks against pure empiricism, we do not by 
any means intend to say that you must be theoretically acquainted 
with all medicine before studying it practically, but you should bring 
a certain knowledge of the fundamental principles of natural science 
with you into the clinic. It is absolutely necessary to have a general 
idea of what you are to expect ; and you must know something of 
the tools before seeing them used, or taking them in your hands. In 
other words, you should know the outlines of general pathology and 
therapeutics, as well as of materia medica, before going to the bed- 



INTRODUCTION. 15 

side of the patient. General surgery is only one part of general 
pathology, hence you should study the latter before entering the sur- 
gical clinic. First, you should gain a clear understanding of normal 
histology, at least of its general parts; pathological anatomy and 
histology should come with general surgery, about the fifth semestre. 

General surgery, the subject of the present lectures, is a part of 
general pathology, as we have already stated ; but it is nearer to 
practice than the latter. It comprises the study of wounds, inflam- 
mations, and tumors of the external parts of the body, or of those 
parts that may be handled from without. Special or topographical 
surgery occupies itself with the surgical diseases of different parts of 
the body, so that the most different tissues and organs are to be con- 
sidered according to their location ; for instance, while we here treat 
only of wounds, of their mode of recovery and treatment in general, 
special surgery treats of wounds of the head, breast, and abdomen, 
paying special attention to the participation of the skin, bones, 
and viscera. Were it possible to pursue the study of surgery for 
several years in a large hospital, and could careful clinical consid- 
eration of individual cases be carried on continuously with the regular 
studies, it would probably be unnecessary to treat of special surgery 
in separate systematic lectures. But, since there are many surgical dis- 
eases that perhaps may not occur for years even in a large hospital, 
but which should be known to the surgeon, the lectures on special 
surgery are by no means superfluous, if they are short and to the point. 

During my student days I occasionally heard the remark : " Why 
should I go to listen to special surgery and pathology ? I can read 
them more conveniently in my room." This may be all true, but un- 
fortunately it is rarely done, unless in the final semestres, when exam- 
ination is approaching. This reasoning is false in another respect 
also : the viva vox of the teacher, as old Langenbeck, in Gftttingen, 
used to say (and he had a viva vox in the best sense of the word), 
the winged word of the teacher is, or should be, more exciting and 
effective than what is read, and the accompanying demonstrations 
of diagrams, preparations, experiments, etc., should render the lectures 
on practical surgery and medicine particularly valuable for you. I 
attach great value to demonstration in medical instruction, for I know 
by experience that this kind of teaching is most exciting and per- 
manent. 

Besides these two sets of lectures on general and special surgery 
you have to practise operations on the cadaver ; this you may post- 
pone to the last semestres. I always like students to take their 
course in operations in the sixth or seventh semestres, along with 
their special surgery, so that I may give them the opportunity of oc- 



10 INTRODUCTION. 

casionally operating, or even of amputating, under my direction. It 
gives courage in practice, if one has during student-life performed op- 
erations on the living subject. When you have followed the lecture? 
on general surgery, you may enter the surgical clinic, and there, in 
the seventh and eighth semestres, openly give an account of your 
knowledge in special cases, and accustom yourselves to collecting 
your ideas rapidly, learn to distinguish the important from the unim- 
portant, and to learn generally in what practice really consists. You 
will thus learn the points where your knowledge is deficient, and may 
perfect yourselves by persevering study. When you have thus com- 
pleted the legal time of your studies, passed your examination, and 
have increased your medical knowledge by a few months or a year in 
various large hospitals at home or abroad, you will be in condition to 
appreciate the surgical cases turning up in practice. But, if you wish 
to devote special attention to surgery and operating, you are still 
far from the goal : then you must become accustomed to operating on 
the cadaver, enter a surgical ward as assistant for a year or two, un- 
tiringly study monographs on surgical subjects, perseveringly write 
out cases, etc. — in short, follow out the practical school from the lowest 
step. You must be fully acquainted with hospital service, even with 
the duties of the nurses ; in short, you should know practically even 
the most minute things appertaining to the care of patients, and 
should even perform the duties yourselves occasionally, so that you 
may be fully master of the entire medical service intrusted to you. 

You see there is much to do and to learn : with patience and perse- 
verance you will accomplish it all ; but these virtues are necessary to 
the study of medicine. 

" Student " comes from " to study ; " hence you must study faith- 
fully ; the teacher indicates to you what he considers the most impor- 
tant ; he may stimulate you in various directions ; what he gives you 
as positive may, it is true, be carried home in black and white, but, to 
cause this positive knowledge to live in you and become your mental 
property, you must depend on your own mental efforts, which form the 
true " study." 

When you conduct yourself as a passive receptacle, you may, it 
is true, acquire the name of a very " learned person," but, if you do 
not awake your knowledge into life, you will never become a good 
" practising physician." Let what you see enter your mind fully, 
warm you up, and so occupy your attention that you must think of it 
frequently, then the true pleasure and appreciation of this mental 
labor will fill you. Goethe, in a letter to Schiller, aptly says : " Pleas- 
ure, comfort, and interest in the affairs of life, are the only realities ; 
all else is vanity and disappointment." 



CHAPTER I. 
SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



LECTURE II. 



Mode of Origin and Appearance of these "Wounds. — Various Forms of Incised Wounds. 
— Appearance during and immediately after their Occurrence. — Pain, Bleeding.— 
Varieties of Haemorrhage ; Arterial, Venous. — Entrance of Air through Wounded 
Veins. — Parenchymatous Haemorrhage. — Hsemorrhagic Diathesis. — Haemorrhage 
from the Pharynx and Eectum. — Constitutional Effects of Severe Haemorrhage. 

The proper treatment of wounds is to be regarded as the most 
important requirement for the surgeon, not only on account of the 
frequency of this variety of injury, but because we so often inten- 
tionally make them in operating, even when operating for something 
that is not itself dangerous to life. Hence we are answerable for the 
healing of the wound, to as great an extent as it is possible by expe- 
rience to judge of the danger of an injury. Let us commence with 
incised wounds. 

Injuries caused by sharp knives, scissors, sabres, cleavers, hatchets, 
etc., represent pure incised wounds. Such wounds are usually recog- 
nizable by the regular sharp borders, where we see the smooth-cut 
surface of the unchanged tissue ; should the instruments be blunt, by 
very rapid motion they may still cause quite a smooth incised wound, 
while by slowly entering the tissue they would give the edges of the 
wound a ragged appearance ; occasionally, the variety of the injury 
does not become evident till the wound is healing, for wounds made 
with sharp instruments heal more readily and quickly (for reasons to 
be given hereafter) than those caused by the slow entrance of dull 
knives, scissors, etc. 

Rarely a perfectly blunt body makes a wound exactly like an incised 
one. . This may occur from the skin being torn through by force ap- 
plied through a blunt object, at a point where it lies over the bone. 
Thus you will not unfrequently see scalp-wounds resembling incised 
2 



18 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

wounds, although they may have been due to a blow from a blunt body, 
or from striking the head against a stone, beam, etc. ; similar smooth 
wounds of the skin also occur on the hand, especially on the volar sur- 
face. Sharp angles of bone may so divide the skin from within that 
it will look as if cut through, as, for instance, when one falls on 
the crest of the tibia, and it divides the skin from within outward. 
As may be readily understood, sharp splinters of bone perforating the 
skin may also make wounds with smooth surfaces. Lastly, the open- 
ing of exit of a bullet-wound, i. e., of the canal which represents the 
passage of a bullet, may sometimes be a sharp slit. 

The knowledge of these points is important, for a judge may ask 
you if a wound has been caused by this or that instrument, in this or 
that manner, points which may greatly affect the bearings in a crimi- 
nal suit. 

Hitherto we have only considered wounds made with a blow or 
stroke. But, by repeated cuts on a wound, the edges may acquire a 
hacked appearance, and thus the requirements for recovery may be 
very much changed. For the present, we leave such wounds out of 
consideration ; their mode of recovery and treatment is just the same 
as that in contused wounds, unless they can be artificially converted 
into simple incised wounds by paring off the jagged edges. The 
various directions in which the cutting instrument enters the body 
generally makes little difference, unless the direction be so oblique 
that some of the soft parts are detached in the form of a more or less 
thick flap. In these Jlap-wounds, the width of the bridge, uniting the 
half-separated portion with the body, is important, because on this 
depends the question as to whether circulation of blood can continue 
in this flap, or if it has ceased, and the detached portion is to be re- 
garded as dead. Flap-wounds are chiefly due to cuts, but may also 
arise from tearing ; they are very frequent in the head, where part of 
the scalp is torn off by a hard blow. In other cases a portion of the 
soft parts may be entirely cut out ; then we have a wound with loss of 
substance. 

By penetrating wounds we mean those by which one of the three 
great cavities of the body or a joint is opened ; they are most fre- 
quently due to stabs or gun-shot injuries, and may be complicated by 
wounds of the viscera or bones. By the general terms longitudinal 
and diagonal wounds we of course mean those corresponding to the long 
or diagonal axes of the trunk, head, or extremities. Diagonal or longi- 
tudinal wounds of the muscles, tendons, vessels, or nerves, are of course 
those dividing these parts longitudinally or diagonally. The symp- 
toms in the person wounded, induced more or less directly by the 
wound, are, first, pain ; then, bleeding and gaping of the wound. 



SYMPTOMS— PAIN. 19 

As - all the tissues, not excepting the epithelial and epidermoid, 
are supplied with sensory nerves, injury at once causes pain. 

This pain varies greatly with the nerve-supply of the wounded 
part, and with the sensitiveness of the patient to pain. The most 
sensitive parts are the fingers, lips, tongue, nipples, external genitals, 
and about the anus. Doubtless, each of you knows from experience 
the character of the pain from a wound, as of the finger. The division 
of the skin is the most painful part ; injury of the muscles and ten- 
dons is far less so ; injury of the bone is always very painful, as you may 
find from any one that has recovered from a fracture; it has also been 
handed down to us from the times when amputations were made with- 
out chloroform, that sawing the bone was the most painful part of the 
operation. The mucous membrane .of the intestines, on being irri- 
tated in various ways, shows very little sensitiveness, as has been occa- 
sionally observed on man and beast ; the vaginal portion of the ute- 
rus also is almost insensitive to mechanical and chemical irritation ; 
occasionally, it may be touched with the hot iron, as is done in treat- 
ing certain diseases of this part, without its being felt by the patient. 
It appears that the nerves requiring a specific irritation, as the 
nerves of special sense, are accompanied by few if any sensory 
fibres. The relation of the sensory nerves of touch to the sentient 
nerves in the skin cannot be regarded as decided, or whether there 
be any decided difference between them. In the nose and tongue, we 
have sensory and sentient nerves close together, so that in both parts, 
besides the specific sense peculiar to the organ, pain may also be per- 
ceived. The white substance of the brain, although containing many 
nerves, is without feeling, as may be seen in many severe injuries of 
the head. The division of nerve-trunks is the severest of all inju- 
ries. Some of you may remember the pain from rupture of a dental 
nerve on extraction of a tooth. Severing of thick nerve-trunks must 
cause overpowering pains. Sensitiveness to pain appears peculiar to 
individuals. But you must not confound this with various exhibitions 
of pain, and with the psychical power of suppressing, or at least limiting, 
this exhibition ; the latter depends on the strength of will, as well as 
on the temperament, of the individual. Vivacious persons display their 
pain, as well as their other feelings, more than phlegmatic persons. 
Most persons maintain that crying, as well as the instinctive powerful 
tension of all the musdes, especially of the masseters, gritting the 
teeth, etc., renders the pain more endurable. Personally, I have not 
been able to verify this statement, and I think it must be a mistake 
of the patients. Strong will in the patient may do much to suppress 
the show of pain. I well remember a woman in the GOttingen clinic, 
when I was a student, who, without chloroform, had the whole upper 



20 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

jaw removed for a malignant tumor, and, during this difficult and 
painful operation, she did not once cry out, although several branches 
of the trifacial nerve were divided. Women generally stand suffer- 
ing better and more patiently than men. But the necessary exercise 
of psychical strength not unfrequently causes subsequent fainting, or 
excessive physical and psychical relaxation, of longer or shorter du- 
ration. You will certainly meet persons who, without any exercise 
of will, show so little pain from severe injury that we can only be- 
lieve that they really feel pain less acutely than others ; I have ob- 
served this most in flabby sailors, in whom all the sequelae of the 
injury are also generally very insignificant. 

The quicker the wound is made, and the sharper the knife, the 
less the pain ; hence, in large and small operations, it has always 
seemed, and very correctly too, for the advantage of the patient, 
that the incisions should be made with certainty and rapidity, par- 
ticularly in dividing the skin. 

The feeling in the wound, immediately after its reception, is a 
peculiar burning. It can scarcely be termed any thing but the feel- 
ing of being wounded ; there are a number of provincialisms for it — 
in Northern Germany, for instance, they say " the wound smarts." 
Only when a nerve is compressed by something in the wound, twisted 
or irritated in some way, there are severe neuralgic pains immedi- 
ately after the injury ; if these do not soon cease spontaneously, or 
after examination of the wound and removal of the local cause, if 
possible, they should be arrested by the exhibition of some internal 
remedy ; otherwise, they will induce and keep up a state of excite- 
ment in the patient that may increase to maniacal delirium. 

To avoid the pain in operations, we now always use anaesthet- 
ics; this subject will be treated of in the course on operations. 
Recently ether has come more into use on account of the number of 
deaths from chloroform. I now use a composition of 3 parts chloro- 
form, 1 sulphuric ether, and 1 absolute alcohol, which seems less 
dangerous than chloroform alone. In England, for some years, 
Spencer Wells, among others, has used and recommended bichloride 
of methyline, claiming that it acts as quickly as, and is less dan- 
gerous than, chloroform. Local anaesthetics, which have for their 
object temporary blunting of the pain in the part to be operated 
on, by application of a mixture of ice and saltpetre, or salt, have 
been again abandoned, or rather they have never been generally 
received. Recently these attempts have again acquired a general 
interest, as it seemed that a suitable method of local anaesthesia had at 
last been found. An English physician, Richardson, constructed a 
small apparatus, by which a stream of pure ether [or, better, rhigo- 



SYMPTOMS— HEMORRHAGE. 21 

line] spray is for a time blown against one spot in the skin, and 
such cold is here induced that all sensation is lost. After procuring 
some of this ether (hydramylather) from England, I was satisfied of 
its perfect action. In a few seconds the skin becomes chalky white, 
and absolutely without sensation ; but the effect hardly extends 
through a moderately thick cutis; and, if the ether be still blown 
against the cut surface, the frozen tissues cannot be distinguished 
from each other, and the knife, being coated with ice, will no longer 
cut. Hence, even in this more perfect form, local anaesthesia can 
only be used advantageously in a few minor operations. My former 
dread, that healing of the wound would be essentially interfered with 
by this freezing of the part, has been shown by experience to be 
groundless. For quelling the pain, and as a hypnotic, immediately 
after extensive injuries or operations, there is nothing better than a 
quarter of a grain of muriate or acetate of morphia ; this quiets the 
patient, and, even if it does not make him sleep, he feels less pain 
from his wound. Quite recently hydrate of chloral ( 3 ss— 3 j, in half 
a glass of water) has been used ; its narcotic action was discovered 
by Liebreich, 1869. Its effect is essentially hypnotic, but very uncer- 
tain ; it cannot supplant chloroform, but is a decided acquisition to 
our materia medica. Locally, for the relief of pain, we employ cold 
in the shape of cold compresses, or bladders filled with ice, applied 
to the wound. We shall refer to this under the treatment of wounds. 
Lastly, we may give hypodermic injections. If, with a very fine 
syringe, furnished with a lance-shaped, sharp canula, which may be 
thrust readily through the skin, we inject a solution of -J-J of a grain 
of acetate or muriate of morphia, this remedy will exercise its nar- 
cotic effect at first locally on the nerves it comes in contact with, and 
then on the brain, as the solution is absorbed and enters the blood. 
Of late, this mode of employing morphia has been exceedingly popu- 
lar ; immediately after an operation, or severe injury, such an injec- 
tion is given, and the pain is at once arrested. 



In a pure incised or punctured wound, haemorrhage is a second im- 
mediate symptom ; its extent depends on the number, size, and variety 
of the divided vessels. At present we shall only speak of haemorrhage 
from tissues previously normal, and distinguish capillary, parenchyma- 
tous, arterial, and venous haemorrhages, which must be considered sep- 
arately. 

As is well known, the different parts of the body vary greatly in 
vascularity, especially in the number and size of the capillaries. In 
spots of equal size the skin has fewer and smaller capillaries than most 



22 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

mucous membranes ; it also has more elastic tissue and muscles, bjr 
which (as we may feel and see in the cold and so-called goose-flesh) 
the vessels are more readily compressed than they are in the mucous 
membranes, which are poor in elastic and muscular tissue ; hence simple 
skin-wounds bleed less than those in mucous membranes. Haemor- 
rhages from the capillaries alone cease spontaneously if the tissue be 
healthy, because the openings of the vessels are compressed by con- 
traction of the wounded tissue. In diseased parts, which do not con- 
tract, even haemorrhage from dilated capillaries may be very consider- 
able. 

Haemorrhage from the arteries is readily recognized, on the one 
hand, because the blood flows in a stream, which sometimes clearly 
shows the rhythmical contractions of the heart ; on the other, by the 
bright-red color of the blood. If there be impaired respiration, this 
bright-red color may change to a dark hue ; thus, in operations on the 
neck, performed to prevent threatening suffocation, and in deep anaes- 
thesia, dark or almost black blood may spurt from the arteries. The 
amount. of blood escaping depends on the diameter of the totally- 
divided artery, or on the size of the opening in its wall. You must 
not, however, believe that the stream of blood corresponds exactly to 
the size of the artery ; it is usually much smaller, for the calibre of 
the artery generally contracts at the point of division ; only the 
larger arteries, such as the aorta, carotids, femoral, axillary, etc., have 
so little muscular fibre that they contract, in their circumference at 
least, to a scarcely perceptible extent. In very small arteries, this con- 
traction of the cut vessel has such an effect that, from the increased 
friction, the blood flows from them without spurting or pulsating ; in- 
deed, in very small arteries, this friction may be so decided that the 
blood flows with difficulty and very slowly, and soon coagulates, so 
that the haemorrhage is arrested spontaneously. The smaller the 
diameter of the arteries becomes, from diminution of the amount of 
blood in the body, the more readily haemorrhage will be arrested spon- 
taneously, while otherwise it would have to be arrested artificially. 
Hereafter, you will often have occasion to see in the clinic how freely 
the blood spurts at the commencement of an operation, and how much 
less it will be toward the end, even when we cut larger vessels than 
were at first divided. Thus decrease of the total volume of blood may 
cause spontaneous arrest of haemorrhage ; the weaker contractions of 
the heart have also some influence in this. Indeed, in internal haemor- 
rhages that we cannot reach directly, we employ rapid abstraction of 
blood from the arm (venesection) as a haemostatic ; in such cases the 
artificial excitement of anaemia is not unfrequently the only remedy 
we have for internal haemorrhage, paradoxical as this may seem to 



SYMPTOMS— HEMORRHAGE. 23 

you at the first glance. Haemorrhages from incised wounds of the 
large arteries of the trunk, neck, and extremities, are always so con- 
siderable that they absolutely require to be arrested, unless the open- 
ings in their walls be very small. But, when the terminal branch of 
an artery is ruptured without a wound of the skin, the haemorrhage 
may be arrested by pressure on the surrounding soft parts; such in- 
juries subsequently induce other changes, to which your attention 
will be called under other circumstances. 

Haemorrhage from the veins is characterized by the steady flow of 
dark blood. This is especially true of small and middle-sized veins. 
These haemorrhages are rarely very profuse, so that, in order to obtain 
a sufficient quantity on letting blood from the subcutaneous veins of 
the arm at the bend of the elbow, we must obstruct the flow of blood 
to the heart. If this were not done, blood would only flow from this 
vein, at the time of puncture, further haemorrhage would cease sponta- 
neously, unless kept up by muscular contractions. This is chiefly be- 
cause the thin walls of the veins collapse, instead of gaping, as the 
arteries do when divided. Blood does not readily flow back from the 
central end of the vein, on account of the valves ; we rarely have any 
thing to do with the valveless veins of the portal system. 

Haemorrhage from the large venous trunks is always a dangerous 
symptom. Bleeding from the axillary, femoral, subclavian or inter- 
nal jugular, is usually quickly fatal, unless aid arrive immediately ; 
wounds of the vena anonyma may be regarded as absolutely mortal. 
The blood does not flow continuously from these large veins, but the 
flow is greatly influenced by the respiration. In operations about 
the neck I have frequently seen patients live after their internal jug- 
ular vein had been wounded ; during inspiration the vessel collapsed 
so that it might have been regarded as a connective tissue string ; 
during expiration the black blood gushed up as from a well, or still 
more like the bubbling up of the water from a deep spring. 

In these veins near the heart, besides the rapid loss of blood, there 
is another element that greatly increases the danger ; this is the en- 
trance of air into the veins and heart, as occasionally takes place with 
a gurgling noise, on deep inspiration, when the blood rushes toward 
the heart ; this may cause instant death, though not necessarily. I 
cannot now enter more explicitly into this very remarkable phenom- 
enon, whose physiological effect has not, as it seems to me, been sat- 
isfactorily explained ; you will again have your attention called to 
this subject by the books and lectures on operative surgery. I shall 
merely mention that, on opening one of the large veins of the neck or 
the axillary vein, there may be a perceptible gurgling sound ; the 
patient instantly loses consciousness, and can rarely be restored to 



U SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

life by instantaneous resort to artificial respiration, etc. Death is 
probably caused by the entrance of air-bubbles, which press forward 
into the medium-sized pulmonary arteries, and are there arrested, and 
prevent further access of blood to the pulmonary vessels. 

I have never met any thing of the kind, although I have seen air 
enter the internal jugular vein, and frothy blood then escape ; this 
had no perceptible effect on the state of the patient. Different ani- 
mals appear to be susceptible, to various extents, to the entrance of 
air into the vessels ; if we throw only a little air into the jugular vein 
of a rabbit it dies ; while we may sometimes throw several syringe- 
fuls into dogs without observing any effects. 

Besides the above varieties of haemorrhage, we distinguish the so- 
called parenchymatous haemorrhage, which is sometimes incorrectly 
identified with capillary haemorrhage. In the normal tissue of an 
otherwise healthy body, parenchymatous haemorrhages do not come 
from the capillaries, but from a large number of small arteries and 
veins, which from some cause do not retract into the tissue and con- 
tract, and are not compressed by the tissue itself. Bleeding from the 
corpus cavernosum penis is an example of such parenchymatous haem- 
orrhages, which also occur from the female genitals and in the peri- 
neal and anal regions, as well as from the tongue and spongy bones. 
These parenchymatous haemorrhages are especially frequent from 
diseased tissue ; they also occur after injuries and operations, as so- 
called secondary hoemorrhages / but we shall speak of these here- 
after. 

One other point we must refer to here : this is, that there are per- 
sons who bleed so freely from a small, insignificant wound, that they 
may die of haemorrhage from a scratch of the skin, or after extraction 
of a tooth. This constitutional disease is called a hmmorrhagic dia- 
thesis ; people affected with it are called hawiophilen. The cause of 
this disease is probably abnormal thinness of the arterial walls ; this is 
congenital in most cases, but may probably result gradually from morbid 
degeneration and atrophy of the vascular tunics. This frightful malady 
is usually hereditary in certain families, especially among the males, the 
females being less liable to it. In these persons haemorrhage is caused 
not only by wounds, but light pressure may induce subcutaneous bleed- 
ing, spontaneous haemorrhages, as from the gastric or vesical mucous 
membrane, which may even prove fatal. It is not exactly in laige 
wounds where medical aid is called at once or very soon, but more 
particularly in slight wounds, that continued haemorrhages occur in 
such persons which are difficult to arrest, partly, as we above stated, on 
account of slight contractility or total lack of muscular tissue in the 
vessels, partly on deficient power of coagulation in the blood. It is 



SYMPTOMS— HEMORRHAGE. 25 

true, the latter point has not been proved from the blood that escaped, 
for in the cases where attention was directed to this point the blood 
flowed like that of a healthy person. 

I shall also call your attention to some peculiarities in haemorrhages 
from certain localities, especially from those in the pharynx, posterior 
nares, and rectum, although, strictly speaking, this comes in the domain 
of special surgery. Wounds of the pharnyx or posterior nares, made 
through the open mouth by accident, are rare, but, as a result of con- 
stitutional disease, we may have very severe spontaneous haemorrhage 
from these parts, or these may result from operations, for we not un- 
frequently have to use knives and scissors here, or to tear out tumors 
with forceps. The blood does not always escape from the mouth and 
nose, but it may run down the pharynx into the oesophagus without 
being perceived. The general effects of rapid loss of blood come on 
rapidly, which we shall soon describe more minutely, but we ars 
unable to discover the source of the bleeding, which may be behind 
the soft palate. The patient soon vomits, and at once throws up large 
quantities of blood ; when this ceases there is another pause, and the 
patient, perhaps also the surgeon, thinks the haemorrhage has ceased, 
till more blood is vomited, and the patient grows still weaker. If the 
surgeon does not recognize these symptoms and apply proper remedies, 
the patient may bleed to death. I remember one case where several 
physicians gave various remedies for vomiting of blood and gastric 
haemorrhage after a little operation in the throat, and the source of 
the bleeding was finally recognized by an experienced old surgeon, 
who arrested it by local applications, and thus saved the life of the 
patient. 

The same thing may happen in haemorrhage from the rectum. 
From an internal wound the blood flows into the rectum, which is car 
pable of enormous distention ; the patient has a sudden desire to stool, 
and evacuates large quantities of blood. This may be repeated sev- 
eral times, till the rectum, irritated by the expansion, either contracts 
and thus arrests the haemorrhage, or till it is finally checked artificially. 

A rapid excessive loss of blood induces changes in the whole body, 
which are soon perceptible. The face, especially the lips, becomes pale, 
the latter bluish, the pulse is smaller, and at first less frequent. The 
bodily temperature sinks most perceptibly in the extremities ; the pa- 
tient, especially when sitting up, is subject to fainting-spells, dizziness, 
nausea, or even vomiting, his eyes are dazzled, and he has noises in the 
ears, every thing appears to whirl around; he collects his strength to 
hold himself up, he becomes unconscious, and finally falls over. These 
symptoms of syncope we refer to rapid anaemia of the brain. In a 
horizontal posture this soon passes off. Persons often fall into this 



26 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

state from very slight loss of blood, occasionally more from loathing 
and aversion to the flowing blood than from weakness. A single 
fainting of this kind is no measure of the amount of blood lost ; the 
patient soon recovers his forces. 

Should the haemorrhage continue, the following symptoms appear 
sooner or later: the countenance grows paler and waxy, the lips 
pale blue, the eyes dull, the bodily temperature is lower, the pulse 
small, thready, and very frequent, respiration incomplete, the patient 
faints frequently, constantly grows more feeble and anxious ; at last he 
remains unconscious, and there is twitching of the arms and legs, which 
is renewed by the slightest irritation, as by the point of a needle, etc. ; 
this state may pass into death. Great dyspnoea, lack of oxygen, is one 
of the worst signs, but even here we should not hesitate ; we can often 
do something even after apparent death. Young women especially 
can bear enormous loss of blood without immediate danger to life ; you 
will hereafter have occasion to witness this in the obstetrical clinic. 
Children and old persons can least bear loss of blood ; in young children 
the results of the application of a leech are often evident for years by 
a very pallid look and increased excitability. In very old persons great 
loss of blood, if not immediately fatal, may induce obstinate collapse, 
which after days or weeks passes on to death ; this is probably because 
the loss of blood is immediately supplied by serum, and in old persons 
the formation of blood-corpuscles goes on slowly; the greatly-diluted 
blood proves insufficient to nourish the tissues, whose nutrition is at 
any rate very sluggish. 

When the patient comes to himself after severe haemorrhage, he 
has excessive thirst, as if the body were dried up, the vessels of the 
intestinal canal greedily take up the quantities of water drunk; in 
strong, healthy persons, the cellular constituents of the blood are 
quickly replaced, it is true we do not exactly know from what source ; 
after a few days, in a person otherwise healthy, we can perceive few 
signs of the previous anaemia ; soon, too, his strength has recovered 
from the exhaustion. 



LECTURE III. 

Treatment of Haemorrhage. — 1. Ligature and Mediate Ligature of Arteries.— Torsion. — 
2. Compression by the Finger; Choice of the Point for Compression of the Larger 
Arteries. — Tourniquet. — Acupressure. — Bandaging. — Tampon. — 3. Styptics. — 
General Treatment of Sudden Anaemia.— Transfusion. 

Gentlemen : You now know the different varieties of haemorrhage. 
Now, what means have we for arresting a more or less severe bleeding ? 



TREATMENT OF HAEMORRHAGE— I JGATURE. 27 

The number is great, although we use but few of them — only those 
that are the most certain. Here you have a field of surgical operation 
where quick and certain aid is required, so that the result must be 
unfailing. Still, the employment of these remedies requires practice ; 
cool-blooded quiet, absolute certainty, and presence of mind, are the 
first requisites in dangerous haemorrhage. In such circumstances a 
surgeon may show of what metal he is made. 

Haemostatics are divided into three chief classes : 1. Closure of 
the vessel by tying it — ligation. 2. Compression. 3. The remedies 
that cause rapid coagulation of blood, styptics (from otv<J)G), to contract). 

1. The ligature may be applied in three ways, viz., as ligature of 
the isolated bleeding vessels, as mediate ligature of the latter with 
the surrounding soft parts, or as ligation in the continuity, i. e., liga- 
tion of the vessel at some distance from the wound. 

These varieties of ligation apply almost exclusively to arrest of 
arterial haemorrhage. Venous haemorrhages rarely require ligation — it 
is only occasionally indicated in the large venous trunks ; we avoid it 
whenever we can, as its results may be dangerous. We shall here- 
after inquire in what this danger consists, and at present speak only 
of the ligation of arteries. 

Let us suppose the simplest case ; a small artery spurts from a 
wound : you first seize the artery, as much isolated as possible, best 
transversely, between the branches of a sliding forceps ; then fasten 
the slide, and the bleeding is stopped. The sliding forceps are best 
made of German silver, as it rusts less readily than iron. There are 
many different varieties of these forceps, which are all so arranged that 
when closed they remain fixed in that position ; the mechanism accom- 
plishing this closure varies greatly ; the more simple it is, the better. 
It is interesting to follow the phases of development of this instru- 
ment since the days of Ambrose Pare, before it attained its present 
simple completeness. Of late small spring clamps are not unfre- 
quently employed to compress the bleeding arteries ; these are very 
serviceable, if strongly made. Besides these pincettes, we may also 
use small curved sharp hooks (Bromfield 's artery-hook) to draw out 
the artery, but this is not so good a way, for of course the blood 
would continue to spurt during the subsequent ligation. 

Having seized the artery securely, the next thing is to close it 
permanently ; this is done by the ligature. But satisfy yourself first 
that you have not included a nerve with it, for the coincident ligation 
of a nerve may not only induce continued severe pain, but even dan- 
gerous general nervous affections. For ligating arteries we use silk 
thread of various thickness, according to the size of the artery ; it must 
be good, strong silk, so that it shall not break when firmly tied ; and it 



28 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

should not readily absorb fluids. Have the forceps, which hang from 
the end of the artery, held up, then from below place the silk around 
the artery, making first a simple knot and tying it tightly just in front 
of the forceps, then tie a second knot. Now loosen the forceps ; if the 
ligature is rightly applied, the bleeding must be arrested. The tight- 
ening of the knot must be accomplished by pushing the silk forward and 
stretching it with the points of both fingers. If the silk be good, two 
simple knots, one over the other, will suffice. When the ligature is 
firmly applied, cut one end off short and lead the other out of the 
wound the shortest way. In from 6 to 10 days these can usually be 
removed. When you propose to close the wound entirely, it is best 
to use catgut made pliable by soaking in oil ; the knots and loops 
are gradually absorbed, and only rarely thrown off by suppuration. 

It is not always possible to take up the spurting artery and ligate 
it by itself; occasionally it contracts so strongly into the tissue, es- 
pecially into the muscles or dense cellular tissue, that its isolation is 
impracticable. Under such circumstances it is difficult to complete the 
ligation securely; we are very apt to include the blades of the forceps 
in the ligature, as it is difficult to push the ligature far enough for- 
ward. Such cases are proper ones for mediate ligation. After hav- 
ing pulled forward the bleeding part with forceps or a hook, pass a 
curved needle, held in a needle-holder, around the artery, then tie the 
ligature so as to encircle the entire end of the artery ; tie the knots 
tightly, as above directed ; thus, while closing the mouth of the artery, 
you will enclose some of the surrounding tissue. Mediate ligation is 
only to be regarded as an exceptional proceeding, for the ligated tissue 
dies or the ligature suppurates through very slowly, so that the sepa- 
ration of the latter is much impeded ; of course we must guard against 
including any visible nerve-trunk near the artery in the ligature. In the 
percutaneous mediate ligation of Middeldorpf, we proceed even more 
summarily ; we pass a strongly-curved large needle through the skin, 
under and across the bleeding artery, and again out through the skin ; 
the thread is tied, and, besides compressing other parts, compresses the 
artery ; the thread remains two or three days. I do not recommend this 
method ; it should only be employed in cases of necessity, and as a 
provisional haemostatic. 

Whenever the bleeding artery can be seen in the wound, the haem- 
orrhage is to be arrested by ligature ; but, in those cases where the 
arteries of the periosteum or bone spurt out blood, ligature is impos- 
sible, and other methods, such as compression, come into play. 

If you have to deal with large bleeding arteries, the proceeding is 
just the same, only you must be doubly careful in isolating the 
artery: seize the bleeding end and scrape back the surrounding 



TREATMENT OF HEMORRHAGE— COMPRESSION. 29 

tissue with a small scalpel, then ligate carefully and accurately; in 
most cases, when you have the central and peripheral ends exposed in 
the wound, you should ligate both, for the anastomoses in the arterial 
system are so free that, if the peripheral end does not bleed at once, 
it may do so later. 

The wound from which a copious haemorrhage comes may be very 
small, as a punctured or gun-shot wound. From your anatomical 
knowledge you should know what large vessel may be injured by such 
a wound. If, from the free haemorrhage or its frequent recurrence 
after compression, you are satisfied that ligation is the only certain 
remedy for the bleeding, you have the following alternatives : either 
enlarge the existing wound by careful, clean incisions, and seek for 
the vessel in the wound while the artery is compressed above, and 
ligate, the divided ends of the artery ; or else, while you have the 
bleeding vessel compressed in the wound, you seek the central part of 
the vessel above the wound, and then ligate in the continuity. Both op- 
erations demand accurate anatomical knowledge of the positions of the 
arteries, and practice. Which of these two operations you shall choose 
depends on how you can soonest prudently attain your object, and 
on which of them will require the smaller new wound. If you think 
you can expose the artery in the wound without enlarging it much, 
choose this method as the more certain ; but if you consider this very 
difficult, if at the seat of the wound the artery lies deep under muscles 
and fascia, especially in very muscular or fat persons, make a regular 
ligation of the artery above (toward the heart from) the wound. 

I shall not here discuss the points chosen after years of trial, on 
theoretical and practical grounds, for the ligation of arteries. In op- 
erative surgery, in the text-books on surgical anatomy, and especially 
in the operative course, you will be instructed on this point, and must 
attain practice in certainly finding, neatly exposing, and carefully 
ligating, the artery, in doing which, you cannot accustom yourself to 
too much pedantry and technicality. 

Although the value of the ligature is recognized by all surgeons 
of the present day, still attempts have been constantly made to find 
simpler substitutes which should be just as safe. Some have con- 
sidered it (unjustly, as it seems to me) a great evil to leave in the 
wound a silk thread and a portion of ligated vessel to die and be- 
come putrid. I pass over the attempts and proposals made for allow- 
ing the ligature to heal in the cicatrix, and merely mention torsion 
of the bleeding artery as a mode of closing the vessel mechanically 
till its walls grow together. The bleeding vessel is seized with 
strong, accurately-closing forceps, drawn forward half an inch, and 
twisted on its axis five or six times ; I usually draw it out as far as 



30 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

possible, and twist till it breaks off. In this way I have twisted ves- 
sels from the smallest size to that of the brachial, so as to securely 
arrest the bleeding. If branches leave the artery just above the 
bleeding-point, it will not be movable enough to make the torsion 
securely ; hence I have never tried torsion for the femoral ; but other 
surgeons have done so successfully. 

2. Compression. — Pressure on the bleeding vessel with the finger 
is such a simple, apparent method of arresting haemorrhage, if we 
may call it a method, that it is strange the laity do not resort to it at 
once ; any person that has seen one or two operations would instinc- 
tively hold his finger on the bleeding vessel ; still how rarely people 
do this in a case of accidental wound ! They prefer resorting to all 
sorts of home remedies ; spider-webs, hair, urine, and all sorts of filth, 
are smeared over the wound, or else they run for some old woman 
who can arrest the bleeding by magic. And no one around thinks of 
compressing the wound. 

Methodical compression may be made for one of two purposes, as 
provisional or permanent. 

Provisional compression, which is used till we can determine 
how the bleeding may be best arrested permanently, may either be 
made by pressing the bleeding vessel in the wound against a bone, if 
possible, or by pressing the central part of the artery against the 
bone at some distance from the wound; the former, as we have al- 
ready stated, is to be done when we propose to ligate the trunk ; the 
latter, when we wish to tie the bleeding end of the artery, or to ex- 
amine the wound more carefully. 

Where shall we compress the artery, and how shall we do it most 
effectually? To compress the right carotid, you would place your- 
self behind the patient, and lay the tips of the second, third, and 
fourth fingers of the right hand along the anterior border of the 
sterno-cleido-mastoideus muscle, about the middle of the neck, and 
press firmly against the spine, while you pass the thumb around the 
neck, and with the left hand bend the patient's head gently to the 
wounded side and somewhat backward. You should distinctly feel 
the pulsation of the carotid artery. Firm pressure here is quite pain- 
ful for the patient, for the vagus nerve is unavoidably compressed, and 
the tension of the parts necessarily acts on the larynx and trachea. 
From the free anastomoses of the two carotids, the effect of compres- 
sion of one of them, in arresting bleeding from an artery of the head 
or face, is not generally very great, and perfect compression of both 
vessels requires so much space, that we must generally be satisfied 
with diminishing the volume of the arteries by incomplete compres- 
sion. Compression of both carotids is always a very painful and ter- 



TREATMENT OF HEMORRHAGE— COMPRESSION. 31 

rifying operation for the patient, especially on account of the strong 
secondary pressure made on the larynx and trachea ; hence it is rarely 
employed. 

Compression of the subclavian artery may be more frequently re- 
quired, especially in wounds of this artery in Mohrenheim? s fossa and 
in the axilla. In this operation also you may best stand behind the 
recumbent or half-sitting patient ; with your left hand incline the head 
of the patient toward the wounded (right) side, and push your right 
thumb firmly behind the outer border of the clavicular portion of the 
relaxed sterno-cleido-mastoid muscle, so that you may firmly compress 
the artery against the first rib, at the point where it passes forward 
between the scaleni muscles. Here also pressure is painful, from the 
liability of the brachial plexus of nerves to be included in the com- 
pression ; still, by employing sufficient force, we may completely com- 
press the artery so as to arrest pulsation of the radial. But the thumb 
soon grows tired and loses sensation ; hence various aids have been de- 
vised — instruments by which the compression may be made certainly. 
One of the most convenient means is a short thick key whose wards 
are wrapped in a handkerchief and the handle held firmly in the palm 
of the hand ; you place the wards of the key over the artery, and 
compress it firmly against the first rib. But this cannnot fully replace 
compression by the finger of a skilled assistant, for with the instrument 
you of course cannot feel if the artery slides away from the pressure. 

From its position the brachial artery may of course be readily 
compressed ; in doing this, you place yourself on the outer side of the 
arm, take the arm in your right hand, so as to lay the second, third, 
and fourth fingers along the inner side of the belly of the biceps, about 
the middle of the arm or a little above it, surround the rest of the 
arm with the thumb, and press against the humerus with the fingers ; 
the only difficulty here is. to avoid simultaneous compression of the 
median nerve, which at this point almost covers the artery. By com- 
pressing the brachial artery, we may readily arrest the radial pulse, 
and we may employ this compression with great advantage if we de- 
sire to ligate either the radial or ulnar artery on account of wounds, 
or to amputate at the forearm or the lower part of the arm. 

In haemorrhages from the arteries of the lower extremities we com- 
press the femoral artery at its commencement, that is, immediately 
below JPoupartfs ligament. Here, where it lies just in the middle be- 
tween the tuberculum pubis and anterior inferior crest of the ileum, 
the artery should be pressed against the horizontal branch of the pubis. 
The patient should be recumbent ; compression should be made with 
the thumb, and is easy, because at this point the artery is superficial. 
As far down as the lower third of the thigh, the femoral artery may 



32 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

be compressed against the femur, but this can only be done certainly 
by the finger in very thin persons ; in most cases we employ for this 
purpose a special compress called a tourniquet. 

By a tourniquet we mean an apparatus by which we press an 
elongated oval piece of wood or leather, a pad, against an artery, and 
this against the bone, by means of a twisting, screwing, or buckling 
mechanism. Since a long compression of the brachial or femoral ar- 
teries is very fatiguing, we may advantageously call it to aid in com- 
pressing these arteries. The form of instrument that we now employ 
is the screw tourniquet of Jean Louis Petit. The pad, which is mov- 
able on a band, is to be applied exactly over the point corresponding 
to the artery, and opposite the screw, under which a few folds of linen 
are to be placed, to prevent too great pressure on the skin. Then 
buckle the band around the extremity, and by means of the screw and 
band draw the pad tighter till the subjacent artery ceases to pulsate. 
In an amputation-wound, if we do not at once see the mouth of the 
artery, we may loosen the screw slightly and permit a little blood to 
escape from the artery, which at once shows its position ; then screw 
up the tourniquet at once, and ligate the artery. This is the great ad- 
vantage of the screw. When the apparatus is well made and careful- 
ly applied, it is of excellent service. It is true, the band around the 
limb unavoidably compresses the veins, especially the subcutaneous 
veins ; nevertheless, on account of the pad, it acts chiefly on the artery. 
With a piece of broad bandage and a round block of wood, or a roller 
of bandage and a short stick, you may readily improvise such a tour- 
niquet ; still, if this improvised apparatus does not secure the artery 
very firmly and securely, I should advise more certain modes of com- 
pression, of which I shall speak immediately. The facility of check- 
ing even considerable haemorrhages by means of the tourniquet, might 
delude us into leaving it on for a long while, until the bleeding 
stopped of itself, and we should thus escape the trouble of ligating. 
This would be a great error. If the tourniquet remains on half an 
hour, the extremity below it grows blue, swells, loses sensation, and 
circulation in the part may be entirely arrested, and it will die; 
through your whole life you would blame yourself for such an error, 
which might greatly endanger the life of your patient. 

Hence, application of the tourniquet is only admissible as a pro- 
visional haemostatic. It is almost impracticable to compress a large 
artery with the finger till the haemorrhage shall be certainly arrested 
spontaneously. Still, cases may arise where compression with the 
finger is the only certain mode of arresting bleeding from smaller ar- 
teries, as in haemorrhages from the rectum or deep in the pharynx, 
when other means have failed; here, compression with the finger 



TREATMENT OF HEMORRHAGE— COMPRESSION. 33 

must sometimes be continued half an hour to an hour, or longer, for 
ligation of the internal iliac in the former case, and of the carotid in 
the latter, are as dangerous as they are uncertain for a permanent ar- 
rest of the bleeding. 1 

Quite recently the genial surgeon and obstetrician, Simpson, of Ed- 
inburgh, whom you already know as the introducer of chloroform, 
has recommended a method which I cannot recognize as a perfect sub- 
stitute for ligation, but which is in many cases of practical use ; this 
is the compression of the bleeding artery by a needle — acupressure. 
Acupressure may be made in various ways. For instance, in an am- 
putation-flap, you introduce a long insect, or sewing-needle, nearly 
vertically through the skin and soft parts to within one-quarter or 
one-half an inch of the artery ; turn the needle horizontally, bring its 
point close over or under the artery, and at about the same distance 
from the artery you push it into the soft parts, and pass it out through 
the skin nearly vertically, so that the artery shall be compressed be- 
tween the needle and the soft parts, or, still better, against a bone. 
Should this compression not act perfectly, as it would rarely be likely 
to in large arteries, if the first needle was applied above the artery, 
pass a second one below it, and so compress the artery between the 
two needles, or else press the artery against the needle by means of 
a wire loop. In amputations I prefer acupressure by torsion ; I pass 
the needle transversely through the artery, which is drawn forward, 
and with the needle make a half or whole rotation in the direction of 
the radius of the surface of the flap, until the bleeding is arrested, 
and then insert the point of the needle into the soft parts. The 
needles may be removed after forty-eight hours, without renewal of 
bleeding. The extensive experience of English surgeons in the suc- 
cess of this bold operation first gave me courage to try it, and I must 
acknowledge that in several amputations, even of the thigh. I have 
seen no objection to it. I cannot quite believe that acupressure will 
altogether displace ligation, as /Simpson prophesied. In this opera- 
tion, to which I have resorted in most of my amputations for several 
years, I employ long golden needles with large heads, because other 
metals rust easily, and silver is too soft, and platinum too expensive. 

Quite recently Von JBruns has applied small ligature rods, with 
which loops of silk are applied around and retained against the 
artery, previously drawn out. These, like acupressure-needles, are re- 
moved after forty-eight hours. I have just tried this procedure with 
perfect success on the femoral artery in an amputation of the thigh. 

In venous haemorrhage, or bleeding from numerous small arteries, 
especially in so-called parenchymatous haemorrhage, a regular tampon 
must be applied, by means of bandages, compresses, and charpie. 
3 



34 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

If you have a haemorrhage from the arm or leg, that you wish to 
arrest by compression — if, for instance, large quantities of blood are 
being poured out from a dilated diseased vein, or if there be bleeding 
from numerous small arteries — you may apply a bandage firmly from 
the lower to the upper part of the extremity, having previously covered 
the wound with a compress and charpie, and after applying several 
thicknesses of linen along the course of the chief artery of the extremity. 
For the latter purpose you may also employ the graduated compress, 
which you will learn to make in the course on bandages. To this, 
which is called Thederi's dressing, it is well to add a splint, to keep 
the extremity perfectly quiet, for the bleeding is readily renewed by 
muscular contractions. These graduated compresses, carefully made, 
are particularly serviceable on the battle-field, in gun-shot and punc- 
tured wounds ; by their aid we may arrest haemorrhage from the radi- 
al, ulnar, anterior and posterior tibial, and even from the brachial and 
femoral arteries. In the former or smaller arteries, by leaving the dress- 
ing on. six or eight days, we may arrest the bleeding permanently, 
but in the latter it only acts as a provisional haemostatic ; it must be 
followed by ligation, if we wish to be at all sure of avoiding a recur- 
rence of the bleeding. "We may also employ compression in haemor- 
rhages from the thorax, as in case of parenchymatous haemorrhage 
after removal of a diseased breast; here we may dress the wound with 
compresses and charpie, and retain them in position by bandages 
around the thorax. But, for such a bandage to be efficacious, it must 
be very annoying to the patient ; on the whole, it is better to ligate 
the bleeding arteries, even if there should be many of them ; by so 
doing, both you and your patients will be better off, for you will not 
be worried and disturbed by the secondary haemorrhages following 
these operations as a result of hasty ligation and insufficient compres- 
sion. 

In some parts of the body you cannot employ compresses, as in 
bleeding from the rectum, vagina, or posterior nares. Here the tam- 
pon (from tampon, plug) is serviceable. There are many varieties of 
tampons, especially for haemorrhage from the vagina or rectum. One 
of the simplest is as follows: Take a four-cornered piece of linen, 
about a foot square ; placing the middle of this over two, three, or five 
fingers of your right hand, pass it into the vagina or rectum, and fill 
the space left by the removal of your hand with as much charpie as 
you can get in, so that the vagina or rectum will be fully distended 
from within, and thus strong pressure t»e made on its walls ; when the 
haemorrhage is arrested, leave the tampon in till the next day, or longer 
if necessary, then remove it by gentle traction on the linen, which 



TREATMENT OF HEMORRHAGE— STYPTICS. 35 

serves as a sac for the charpie. You may also make a ball of charpie or 
linen by wrapping a string around it, and leave a long string hanging 
out by which to remove it ; as such a tampon may be either too large 
or too small, I prefer the first method, in which we may fill the linen 
sac to the extent we desire. 

If the bleeding come from the portio vaginalis uteri, after an 
operation, for instance, a more certain way is to hold back the poste- 
rior wall with a large /Sims' s speculum, thus bringing the portio vagi- 
nalis into view, and press a tampon firmly against the bleeding part ; 
for it requires an incredible quantity of charpie to fill the vagina of a 
woman who has borne many children, so that no blood can pass 
through, and it causes great pain. 

In profuse bleeding from the nose, which mostly comes from the 
posterior part of the inferior meatus, and not unfrequently from the 
posteriorly-situated cavernous tissue of the lower turbinated bone, 
plugging the nose from the front proves inefficacious and useless ; the 
b 1 ceding continues, and the blood either passes into the pharynx or 
flows out of the other nostril, as the patient presses the velum pen- 
dulum palati against the wall of the pharynx, and shuts off the upper 
part of the pharyngeal cavity. Hence, we must be prepared to plug 
the posterior nares ; we may do this by the aid of JBelloc's sound. This 
exceedingly convenient instrument consists of a canula about six inches 
long and slightly curved at one end; in the canula is a steel spring of 
much greater length, with a perforated button-head at one end. You 
prepare beforehand a thick plug large enough to fill the posterior nares, 
and have a thread attached to it. (You may make this plug by lay- 
ing threads of charpie side by side and tying them tightly together in 
the middle with a silk thread.) You apply this plug by passing the 
instrument, with retracted spring, through the inferior nasal meatus, 
then pushing the spring forward till it appears below the velum in the 
mouth. Pass the thread attached to the plug through the eye in the 
head of the spring, tie it there, and draw both canula and spring out 
of the nose ; the thread attached to the latter and the plug fast to this 
must follow, and if you draw tightly on the thread the plug is pressed 
firmly into the posterior nares ; if the bleeding be now arrested, as it usu- 
ally is, if the plug (which should not be long enough for its end to reach 
the larynx) was not too small, you cut loose the thread, leave the plug 
in till the next day, then withdraw it by the thread left hanging from 
the mouth ; this is usually easily done, as the plug is generally covered 
with mucus and is consequently smooth. As this instrument is not 
always at hand, we may use an elastic catheter or a thin slip of whale- 
bone for the same purpose, introducing it through the nose, seizing it 



36 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

with the finger behind the velum, and bringing the end out of the 
mouth to tie the thread to it. But the employment of this substitute 
requires more dexterity than is necessary for Bellows sound. 

3. Styptics are remedies which act partly by causing contraction 
of the tissue, partly by inducing rapid and firm coagulation. The num- 
ber of remedies recommended is immense ; we shall only mention those 
that have a proved reputation under certain circumstances. 

Cold not only irritates the arteries and veins to contract, but also 
makes the other soft parts contract and thus compress the vessels ; the 
current of blood is gradually more obstructed, and may even stagnate 
entirely, when the part is completely frozen. It seems to me, however, 
that the recommendation of cold as a haemostatic is often carried too 
far ; I advise you not to rely on it too much. Cold may be employed 
as follows : first, we may squirt ice-water against the bleeding wound, 
or into the vagina, rectum, into the bladder through a catheter, into 
the nose or mouth — here the mechanical irritation of a strong stream 
of water is added to that of the cold ; or you may lay pieces of ice on 
the wound, or introduce them into the cavities, or have them swallowed 
in gastric or pulmonary haemorrhage ; or, lastly, you may fill a bladder 
with ice and apply to the wound, to be left on for hours or days. 

The absolute quiet to be observed in all haemorrhages and the dim- 
inution in size of the arteries as a result of the bleeding that has 
already occurred, may often have more effect in arresting the haemor- 
rhage than ice has, while it receives all the credit. I will not dissuade 
you from using cold in moderate parenchymatous haemorrhages, but 
do not expect too much from it in bleeding from large arteries, and 
do not waste too much time over it, for time is blood — blood is life. 

The same is true of the common local remedies, vinegar, solution 
of alum, etc., which also contract the tisues and thus compress the 
vessels ; they are very good for arresting capillary haemorrhages from 
the nose, but you must not expect any thing' wonderful from them. 

The hot iron, ferrum candens, causticum actuale, acts by charring 
the ends of the vessels and the blood, and the escape of the blood is 
arrested by the resulting firm slough. You only need to hold a rod of 
iron with a wooden handle at one end, and at the other a small iron 
head heated to a white heat, close to the bleeding spot, to form a black 
crust instantly ; indeed, the tissue occasionally blazes up even from the 
radiated heat. A red-hot iron pressed on the bleeding spot has the 
same effect, but is apt to cling to the resulting eschar and pull it off 
again. This iron rod (cautery iron) is usually heated to the proper 
degree in a furnace with bellows. Under some circumstances the hot 
iron may be very convenient for arresting haemorrhage ; formerly, be- 



TREATMENT OF HEMORRHAGE. 37 

fore ligation was known, it was the most celebrated styptic. The 
Arabian surgeons usually heated their amputating knives red hot, a 
proceeding that even Fdbricius Hildanus extolled, although he pre- 
ferred burning the bleeding arteries separately with fine-pointed cau- 
teries, in which he must have had an enviable expertness. 

Quite recently a similar method has been invented, namely, the 
use of platinum heated by the galvanic battery. This is the so-called 
galvano-caustic introduced into Germany by Middeldorpf, which may 
sometimes be employed with advantage. As you may readily under- 
stand, in practice we have not always at hand an iron properly shaped 
for arresting haemorrhage, such as you see in the surgical clinics. 
Dieffenbach, the most talented German operator of this century, who 
was at the same time a most original man, once, lacking other means, 
being alone in a poor dwelling, arrested a haemorrhage following the 
extirpation of a tumor from the back, by means of the tongs which he 
heated in the stove. A knitting-needle, stuck in a piece of wood or a 
cork, and heated at the lamp, may answer the purpose of the hot iron. 

A remedy which not only equals, but occasionally surpasses, the 
hot iron in its effects, is liquor ferri sesquiclilorati • this forms with 
the blood such a leathery, adherent coagulum, that it acts excellently 
as a styptic. To apply it, you press a piece of charpie, moistened with 
it, firmly against the wound ; after having washed off the blood with a 
sponge, hold it there from two to five minutes ; you will thus be able 
to arrest quite free arterial haemorrhage. If the first application does 
not succeed, try it a second or third time ; this remedy will rarely fail 
you ; but it makes a slough, behind which there is often sanious sup- 
puration mixed with gas-bubbles ; hence we should not employ this 
styptic needlessly. 

The application of punk and blotting-paper to bleeding wounds is 
an old popular remedy ; the punk sticks fast to the blood and the wound, 
if the bleeding be not excessive ; in haemorrhages at all free it is useless 
without simultaneous compression ; occasionally it is very efficacious, 
and is highly praised by some surgeons. Dry charpie pressed firmly 
on the wound has the same effect, according to my experience. 2 

Other haemostatics are oil of turpentine and aqua Binelli, in 
which the creosote is chiefly efficacious ; concerning the former alone 
have I any experience, and I recommend it strongly ; when I studied 
in Gottingen, it was also specially recommended by my preceptor, 
Baum, and I used it once with such striking benefit in a doubtful case 
that I have a certain devotion for it. It is, however, an heroic remedy, 
not only because application of turpentine-oil to a wound induces 
severe pain, but also because it excites severe inflammation in the 
wound and its vicinity. I will relate the case where I employed it. 



38 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

A young, feeble woman suffered, after confinement for many months, 
from an extensive suppuration behind the right breast, between the 
mammary gland and the fascia of the pectoral muscle ; numerous inci- 
sions had already been made through the breast, and about its circum- 
ference, to give free access to the pus which formed in such quantities ; 
but the openings soon closed again, and new ones had to be made, as 
the wound did not heal from below. From one such incision, which I 
made quite extensive, severe haemorrhage resulted, blood welled up 
from the depth of the abscess, and I was unable to find the bleeding 
vessel ; it flowed continuously, as if from a spring. First, I filled the 
cavity with charpie and applied a bandage; the blood soon oozed 
through this dressing ; I removed it and injected ice-water into the 
various openings ; the bleeding moderated. I again made firm compres- 
sion, and the haemorrhage seemed arrested. I had scarcely reached my 
room in the hospital when I was called by the nurse, because the blood 
again oozed through the dressing ; the patient had fainted, was pale 
as a corpse, and the pulse was very small. The bandage had to be 
removed at once. I now thrust pieces of ice through the different 
openings into the cavity under the breast ; still the bleeding was not 
arrested. The patient went from one fainting-fit into another, the bed 
flowed with blood and ice-water, the patient lay unconscious, with cold 
limbs and upturned eyes, the nurses constantly trying to resuscitate the 
patient by holding ammonia to the nose, and rubbing the forehead with 
Cologne water. At the commencement of my surgical life, unaccus- 
tomed to quiet and presence of mind in such scenes, caused by my own 
act, I shall never forget this situation. I thought it would be abso- 
lutely necessary to amputate the breast at once, to find and ligate the 
bleeding artery, but determined to make one more attempt with oil 
of turpentine. I soaked a few wads in this substance, introduced 
them into the wound, and the bleeding was instantly arrested. The 
patient soon revived ; the turpentine, which was left in twenty-four 
hours, caused intense reaction in the abscess cavity, whose walls be- 
came detached. Subsequent active granulation induced in three weeks 
a cure which had for months been patiently and perseveringly sought 
in vain by physician and patient. I cannot explain to you how bleed- 
ing is arrested by oil of turpentine and creosote ; they do not cause 
particularly firm coagulation of the blood ; probably the intense irrita- 
tion they induce excites a peculiarly energetic contraction of the di- 
vided capillaries. 

You will rarely see styptics employed in the surgical clinic ; they 
are rather favorites of the practising physician, who is not accustomed 
to ligate arteries. Where we can ligate or compress, we should not 



TRANSFUSION OF BLOOD. 39 

use styptics. In parenchymatous bleeding from the face, neck, or 
perinaeum, we may resort to styptics with advantage, if it makes no 
difference whether the wound suppurates subsequently ; but, if the 
haemorrhage be considerable, and styptics fail, subsequent ligation is 
much more difficult, as the wound is often terribly smeared up by the 
previous applications. 

In surgery you have nothing to expect from the internal adminis- 
tration of remedies recommended as styptics. Absolute quiet, keeping 
cool, narcotics, purgatives, may occasionally be of great assistance in 
congestive haemorrhages, but their action is far too slow for the bleed- 
ing that we have to deal with in surgery. 

The general debility from profuse haemorrhage will, of course, 
be most effectually combated by arresting the bleeding ; but, while 
doing this, you may have the assistants, not otherwise employed, try 
to resuscitate the patient by smelling-salts, sprinkling with water, 
etc. You should not yourself join in these attempts, till the bleed- 
ing is stopped ; then you may give wine, rum, or brandy, warm coffee, 
or soup ; cover the patient up warmly ; let him take a few drops of spir- 
its of ether or acetic ether, and smell ammonia, etc. I have never had a 
patient bleed to death under my hands, but have met two cases where 
the patients died, two and five hours after extensive operations, 
with dyspnoea and spasmodic contractions, apparently as a result of 
the great loss of blood ; these cases decided me, under similar cir- 
cumstances, to inject the blood of a healthy person into the veins of 
the bleeding one. This operation, which is called transfusion, is 
quite ancient ; it originated in the middle of the seventeenth cen- 
tury. After the world had been for a time astonished at its boldness, 
it was laid aside and derided, but, toward the end of the last century, 
it was again drawn from the shade of oblivion by English physicians, es- 
pecially the obstetricians. After JDieffenbach had made some attempts 
again to introduce transfusion into Germany without success, Mar- 
tin has of late the credit of again calling attention to it as a mode 
of saving life, while JPanum has exhaustively treated the subject in 
physiological experiments. Statistics show that the operation was 
favorable in the great majority of cases, and was very easy to per- 
form. Although formerly lamb's blood was successfully injected into 
man's veins, it is best and most natural to choose blood from a young, 
healthy, and strong human being. The instruments required are a 
knife, forceps, scissors, a fine canula, and a 4-6 oz. glass syringe to 
fit it. We open the "vein of a healthy, strong young man, in the man- 
ner hereafter to be described, and receive first about four ounces of 
the blood in a rather high bowl, standing in a basin full of blood-warm 
water; the blood, flowing into the bowl, is beaten with a twirling 



40 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

stick, till the fibrine is separated. While this is being done, the most 
perceptible subcutaneous vein at the bend of the elbow of the patient 
is to be exposed by an incision through the skin ; then two silk threads 
are to be passed under it, the lower one is drawn on without 
closing it, so that no blood may escape by the subsequent fine oblique 
incision made in the vein by the scissors. The canula is passed up 
into the now gaping opening in the vein, and the upper thread is 
crossed over it without being tied ; some blood should escape through 
the canula, so as to fill it and drive out the air. Meanwhile, the as- 
sistant has completed the venesection and filtered the whipped blood 
through a fine cloth ; then the previously-warmed syringe is to be 
filled with the blood, inverted and the air forced out, placed firmly in the 
canula, and the blood injected very slowly. Experience has taught 
that it is not advisable to inject more than four to eight ounces of 
blood, and that this is enough to recall life. We should never empty 
the syringe entirely, and cease at once if the patient has dyspnoea. 
When the injection is completed, we remove the ligatures and canula, 
and treat the wound as after venesection. There has been much dis- 
pute, as to whether or not it is necessary to remove the fibrine from 
the blood to be injected. P (mum's experiments have clearly proved that 
fibrine is not necessary in resuscitation by transfusion, and that, even 
with the greatest care, it may act injuriously by clotting. The active 
element in this operation appears to be the introduction of blood-cor- 
puscles as bearers of oxygen. Possibly, transfusion has a still wider 
future ; at all events, it might be worth while to try it in excessive 
anaemia, resulting from other, sometimes unknown, causes, even al- 
though, according to Panum's excellent observations, the blood itself 
does not nourish, but is only the bearer and forwarder of nourish- 
ment. The experiments made by JVeudorfer, during the last Italian 
War, on the wounded who had become anaemic from profuse suppura- 
tion, had no brilliant results, it is true, but further trials should be 
made of this operation, which with proper care is not dangerous. 

Hueter has studied transfusion most thoroughly of late ; he rec- 
ommends injecting beaten and filtered venous blood into an artery 
(such as the radial or posterior tibial) in a peripheral direction, just 
as was once done by Von Graefe. As Hueter has demonstrated that 
this arterial transfusion is easier than the venous, it deserves the 
preference, because by it we avoid the danger of pulmonary emboli. 
No abnormal symptoms occurred where Hueter operated on the hands 
and feet ; but I doubt if it would often be possible to introduce a 
canula into these small arteries in a patient bleeding to death ; in 
such a case we should have to choose the brachial artery. 

The enormous increase of bodily temperature, the occurrence of 



GAPING OF THE WOUND. 41 

bloody urine, and other symptoms, following this operation, show 
that it has a very decided influence on the physiological action of the 
organism. As this operation has always been performed in vain by 
myself and my assistants, I am much less in favor of it than formerly, 
when I only knew it from the accounts of others. 

I cannot here enter on the treatment of the later results of con- 
siderable haemorrhages ; it will be evident to you that, in general, the 
chronic effects, the deficient formation of new blood, must be com- 
bated by strengthening and nourishing diet and medicines. 



LECTURE IV. 

Gaping of the Wound. — Union "by Plaster. — Suture ; Interrupted Suture ; Twisted Su- 
ture.— External Changes perceptible in the United Wound. — Healing by First In- 
tention. 

After entirely arresting the haemorrhage from a wound, cleaning 
its surface with cold water, and satisfying yourself of its depth, and 
of the character of the parts divided, in doing which you must notice 
whether a joint, or one of the cavities of the body, has been opened, 
a large nerve divided, or a bone exposed or injured, etc., you will 
turn your attention to the third symptom in the fresh wound, that is, 
its gaping. On division skin, fascia, and nerves will separate, partly 
from their own elasticity, partly because they are attached to the mus- 
cles, which, from their contractility, shrink together immediately 
after being divided, and whose cut surfaces, consequently, especially 
in transverse wounds, are more or less separated. 

At first we shall consider only those incised wounds where there has 
been no loss of substance, but only a simple division of the soft parts. 
For such a wound to heal quickly, it is desirable that the two edges 
should be brought exactly together, as they were before the injury ; 
to accomplish this, we make use of strips of adhesive plaster or of 
sutures. 

In wounds where the cutis is scarcely divided, as so often happens 
in the common incised wounds of the fingers, we may use isinglass- 
plaster with advantage. It consists of a solution of ichthyocolla in 
water, mixed with a little spirits of wine, painted over a thin, firm 
silk stuff or paper ; the back is often painted with tincture of benzoin, 
which gives the plaster a pleasant odor. As the plaster readilj loos 



42 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

ens under moist compresses, it is often advisable to paint it with col- 
lodion, after it has dried. 

Collodion is a solution of gun-cotton in a mixture of ether and 
alcohol. If this fluid be painted over the plaster and the skin immedi- 
ately adjacent, the ether quickly evaporates, and a fine membrane in- 
soluble in water remains, often puckering up the skin. A further 
therapeutic use may be made of this contractile action of collodion, 
by painting it on the inflamed skin, either directly, or, still better, after 
covering the part with a thin, coarse-meshed cotton-cloth (gauze) ; 
this causes moderate, even pressure. When you use collodion to 
fasten the plaster, avoid applying it directly to the wound ; this not 
only causes unnecessary pain, but may also induce inflammation and 
suppuration of the wound, which should be particularly avoided. 

If the cutis be divided, and the plaster must resist any consi dera- 
ble tension in keeping the edges of the wound together, ichthyocolla- 
plaster proves insufficient, and adhesive plaster must be employed. 
Of this we have two varieties, besides innumerable modifications, from 
attempts to make it cheaper and better. Emplastrum adhsesivum, 
emplastrum diachylon compositum, our common adhesive plaster, con- 
sists of olive-oil, litharge, resin, and turpentine. While it is fluid 
from heat it is painted on linen, and it is generally used in strips, which 
are laid over the wound, and hold its edges together. When fresh, 
this plaster adheres excellently, but loosens after a time, if moist com- 
presses be applied over it. Very sensitive skins are irritated by this 
plaster if it is frequently applied; then we may resort to the other adhe- 
sive plaster, the emplastrum cerussce (emplastrum adhsesivum album), 
which is prepared from olive-oil, litharge, and white lead, with hot 
water. This plaster adheres less firmly, but has the advantage of 
smearing the lips of the wound less than the yellow plaster. A mix- 
ture of equal parts of the two plasters lessens the objections and com- 
bines the advantages. 

In large wounds we now avoid the use of adhesive plaster more 
than formerly, and in its place employ the suture more commonly. 
When we wish to unite wounds by the suture, we generally choose 
between two varieties, the interrupted (sutura nodosa) and the twisted 
suture (sutura circumvoluta). There is some truth in the assertion 
that, by the introduction of a foreign body, such as a thread or needle, 
we maintain constant irritation in the edges of the wound, but this 
cannot equal the great advantage obtained by the certainty of ad- 
justment of the edges of the wound by means of sutures. Hence, 
except adhesive plaster, almost all substitutes for the suture, in which 
ancient and modern surgery has exhausted itself, after being fashion- 



UNION OF WOUNDS— SUTURES. 43 

able for a time, have been thrown aside. The suture has not yet 
been dropped, and probably never will be, any more than ligation. 

There are certain parts of the body, as the scalp, hands, and feet, 
where we try to avoid sutures, because there certain inflammatory 
processes, which have often been ascribed to the suture, readily assume 
a dangerous character ; but I think there is a good deal of prejudice 
in this. Wounds of the head are especially prone to cause inflamma- 
tions of the skin and subcutaneous tissue ; extensive statistics have 
never shown whether this tendency is particularly increased by the 
irritation from sutures. There are many articles of faith handed 
down from preceptor to pupil, from one text-book to another ; many 
of them are a sort of Hippocratic traditions, full of practical truth ; to 
these I pay full respect ; others are based on accidental observations 
and consequent judgments ; among the latter, I class the objection to 
sutures in scalp-wounds. Reviewing my own experience, I remember 
more cases of inflammation following wounds where no sutures were 
introduced than where they were. It is very important, however, at 
once to recognize inflammations beginning in the head, and to remove 
the sutures. The amount of gaping and the forms of the wound (e. g., 
a flap-wound or not) at once show the necessity for sutures. One 
would never take any unnecessary trouble in introducing sutures, un- 
less urged by excess of surgical zeal ; but where, for the reasons above 
given, adhesive plaster will not answer, we should employ sutures. 

For the interrupted suture we use surgical needles and silk thread 
or wire. Surgical needles differ from ordinary ones, in having a lance- 
shaped, ground point, which pierces the skin more readily than the 
round point of a sewing-needle ; they are also of somewhat softer 
steel than English sewing-needles, so that they do not spring so 
much. Their thickness and length vary greatly, according as we 
wish to apply a strong thread deeply where the edges of the wound 
are tense, or only to use a fine thread to bring the edges together ex- 
actly. All needles should, however, have a good-sized eye, so that we 
may not, like a tailor, lose time in threading them, but do so readily 
and quickly. The needle may be either straight or curved. The 
curve should vary with the locality where we wish to sew ; for in- 
stance, very fine, strongly-curved needles are required for sewing about 
the inner canthus of the eye ; large, strongly-curved needles are 
needed for sewing up a perinaeum, ruptured during labor, etc. The 
curvature may either be in the whole needle or only at the pointed 
end ; for instance, for certain operations, it is shaped like a fish-hook ; 
the variety is very great. For sewing such wounds as usually present 
themselves in practice, you need only a few fine and coarse straight 
and variously-curved needles. 



44 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

The thread is usually of silk, whose coarseness corresponds to the 
size of the needle. Formerly I always sewed with the red German 
silk, which has long been used for this purpose ; but in England I 
found a sort of undyed, strongly-twisted silk, which, even when very 
fine, is so strong that, with thread as fine as a hair, we may sew up 
wounds and draw them together. Moreover, this silk imbibes so little 
moisture that it may lie for days in the wound without swelling or ir- 
ritating. Now I use only this so-called Chinese silk. Another mate- 
rial for sutures has been lately used in England and America, viz., 
silver or iron wire, It must be very fine and soft ; the iron wire for this 
purpose is well annealed. The trial of this material was first induced 
by the long-known fact that, when metals were introduced under the 
skin or any where in the body, they usually excited no suppuration, 
but the parts often healed over them. Hence, it was thought that 
the inflammations often occurring at the points of suture might be 
avoided by using metal instead of the animal substance silk. In 
truth, it cannot be denied that this suppuration is less apt to occur 
from metal than from silk thread, still experiments of Simon have 
shown that the suppuration from sutures depends greatly on the thick- 
ness of the thread. From my own experience I can affirm that fine 
silk threads cause as little suppuration along the course of the suture, 
and may heal in, just as well as metal ones. 

We come now to the application of the interrupted suture. You 
do it as follows : with a toothed forceps you first seize one lip of the 
wound ; pass the needle through the skin, about two lines from the 
edge, as deep as the subcutaneous tissue, and bring it out through the 
wound ; now seize the other lip of the wound with the forceps and 
pierce it from the wound up toward the skin, exactly opposite the 
first point of entrance, then draw the thread through and cut it off, 
leaving both sides long enough to tie readily in a knot. Now make 
a simple, or, if the tension of the borders of the wound be great, a 
surgeon's knot, and draw it tight, seeing that the edges of the wound 
are in exact apposition ; then make a second knot, and cut off both 
threads, close to the knot, so that no long ends of thread may get in 
the wound. 

Should you desire to use wire, you thread it as you do the silk on 
the needle, draw a short portion through the eye and bend it, then 
make the suture as above described. When the wire is very soft, we 
can tie a knot with it nicely, just as with a silk thread; still, the 
whole of this manipulation is much less pleasant with wire than with 
silk thread, and on closing the knot the border of the skin is readily 
displaced, or there may be twists, that render the hold less secure ; 



UNION OF WOUNDS. 45 

this is especially apt to happen with our German wire, which has not 
yet attained the softness of the English. The pleasantest wires are 
those made of a mixture of gold and silver and of platinum, of which 
very fine, pliable, and, at the same time, firm wire may be made. [Very 
nice wire is made of lead, and it is supposed by some to be an advan- 
tage that this will break if the parts should swell excessively.] Still, 
how ridiculous it would be to try to substitute these expensive articles 
for ordinary silk, by which millions of wounds have been healed excel- 
lently, and will be in future ! I pass over the many newly-recommend- 
ed modes of fastening the wire by knots or twisting ; they show that 
even those who advocate metallic sutures have found some trouble in 
fastening the knot. I first make a simple knot, draw it together, 
make two or three short twists, and cut off the ends close to the 
twisted part. Wire cuts the edges of the wound, just as silk does, if 
it be very fine. 

I have rarery found the little objections to silk sutures sufficiently 
annoying to make me replace them by metal sutures. Beginners 
generally err in making sutures too tight ; this constricts the edges 
of the wound. When they swell, as they mostly do, this constriction 
is rarely enough to kill the tissue at once, but causes inflammation 
with redness and suppuration about the puncture, which may spread 
and impede healing of the wound if the sutures be not removed in time. 

Straight needles may be best introduced with the fingers; but 
curved needles, especially when they are small or the wound deeply 
seated, are introduced better and more certainly by means of a needle- 
holder. There are numbers of these ; I am in the habit of using 
DieffenbacJi ) s. It consists of a forceps with short, thick blades, be- 
tween which we hold the needle firmly and securely, and introduce it 
through the skin in the direction of its curvature. This perfectly sim- 
ple instrument suffices for almost all cases, and in good hands is sur- 
passed by no instrument for security in holding and introducing the 
needle. Complicated instruments are especially suited for unskilful 
surgeons, says DieffenbacJi, in the unparalleled introduction to his Ope- 
rative Surgery ; not the instrument, but the hand of the surgeon, should 
operate. Practice and habit render this or that instrument indispen- 
sable. Thus some find it complicated and inconvenient to seize the 
lips of the wound with forceps, as I taught you, although this is bet- 
ter than holding them with the fingers ; for me, the latter would be 
very inconvenient. In this matter any one may do as his habits and 
inclination lead him. When I have to sew some deep part — as the 
velum, rectum, or vagina — I always use needles with handles. 

Of course the number of sutures to be applied depends on the 



46 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

length of the wound ; generally sutures half-an-inch apart suffice, but 
where perfect apposition and small cicatrices are very desirable, as in 
wounds of the face, they must be closer, and should alternate between 
coarse ones at a distance from the edge of the wound, and fine ones 
enclosing but a small portion of the edge. 

The second variety of suture, twisted or hare-lip suture, is made by 
passing a long pm with a lance-shaped point through the flaps of the 
wound, and passing a strong cotton or silk thread around it, as I now 
show you. You take the thread in both hands, lay it parallel to and 
immediately over the pin, that is, transversely to the wound, pass it 
under the two ends of the pin from above, and draw on it, so as to 
approximate the edges of the wound exactly (this is the so-called 
Nulltour) ; now you change the threads to the other hands, and, with 
the right thread in the left hand, pass around the left end of the pin 
from above downward, and, with the left thread in the right hand, do 
the same for the right end of the pin ; you change the threads again 
and make four to six similar, so-called figure of eight turns ; then tie 
a double knot and cut the ends off close ; then cut off the ends of the 
pin to a proper length, so that they may not press on the skin, but not 
so short as to prevent their being readily withdrawn subsequently. 

There are a great number of other sutures, which for the most 
part are only of historical interest, and which we here pass over; 
some peculiar forms of suture will be treated in special surgery, under 
wounds of the different parts, as in wounds of the intestine. 

Where are the advantages of the twisted over the interrupted 
suture ? and when do you employ it ? These indications may be re- 
duced to two factors, so that you will consider the interrupted suture 
as the simpler and more common. The twisted suture is preferable — 
1. "When the flaps of the wound are very tense ; 2. When the skin- 
flaps to be united are very thin and without support — in short, where 
the lips of the wound have a tendency to roll in. The needle, remain- 
ing in position in both cases, renders the suture more secure and firm ; 
the needle serves as a sort of subcutaneous splint for the edges of the 
skin ; they are supported by it, and are also held more securely by the 
folds of thread on the outside. In many cases, in applying sutures in 
the face, the interrupted and twisted sutures are applied alternately ; 
the latter serve as supports and to resist tension, the former to in- 
duce more exact union of the edges of the wound. 

When the bleeding has been stopped and the wound united, all 
has been done that is at first necessary. Now let us observe what 
takes place in the closed wound. 



UNION OF WOUNDS. 47 

Immediately after being united, the edges of the wound are gener- 
ally white, from the pressure exercised by the sutures as they com- 
press the capillaries ; rarely the borders of the wound are dark blue ; 
this always indicates great impediment to the return of blood through 
the veins, due to a loss of part of the blood-vessels. It is evident 
that the communication between arteries and veins may be greatly 
disturbed by the division of a large number of capillaries, so that at 
some point in the border of the wound the vis a tergo of the venous 
stream shall be insufficient. On the whole, this dark-blue color of the 
flaps of the wound is rare ; it either disappears spontaneously or a 
small portion of the lip of the wound dies, a symptom to which we 
shall return when speaking of contused wounds, in which it is quite 
common. 

Even after a few hours you find the borders of the wound slightly 
swollen and occasionally bright red; this redness and swelling are 
often absent (especially where the epidermis is thick), but occasionally, 
according to the extent and depth of the wound and tension of the 
skin, it spreads from two or three lines, or to as many inches, around 
the wound ; the usual so-called local reaction about the wound takes 
place in this space. The wound pains slightly, especially on being 
touched. All this may be best seen in children and women with 
delicate skin. About wounds of the face, especially of the eyelids, 
we often notice extensive oedema in twenty-four hours; this fre- 
quently terrifies the friends, but is usually free from danger. 

In a considerable number of cases, if the sutures be not too tightly 
applied, the edges of the wound appear unchanged not only at the 
time, but till the cure is complete. But often enough the wound 
shows the cardinal symptoms of inflammation ; pain, redness, swell- 
ing, and increased heat, of which you may satisfy yourself by placing 
your finger on the parts about the wound, then on a distant part of 
the body. The process going on at the wound, and ending in the 
union of its edges, comes under the combination of morphological and 
chemical metamorphoses comprised by the name inflammation, and, 
in the case under consideration, would be termed traumatic inflam- 
mation, that is, an inflammation caused by an injury (rpaviia). 

As a rule, these local symptoms have reached their height in 
twenty-four hours ; if by that time they have not exceeded the above 
bounds, you consider the process as taking a normal course. It is a 
marked peculiarity of traumatic inflammation, that, in a pure form, 
it is strictly limited to the borders of the wound, and does not extend 
without special cause. It is not unusual for these symptoms to remain 
at the same height the second or even the third day ; but by the third 
or fifth day, the redness, swelling, pain, and increased temperature, 



48 SIMPLE INCISED WOUNDS OF THE SOFT PARTS 

should have disappeared mostly or entirely. If the symptoms still 
increase the second, third, and fourth days, or if some of them, as se- 
vere pain, and great swelling, recur at this time, or if they remain at 
the same point to the fifth or sixth day, it is a sign that the course 
differs in some way from the normal. This will be especially evident 
from the general condition of the patient. The whole body reacts to 
an irritation of one part of it, not in a perceptible manner, in small 
wounds, it is true. We shall refer to this general reaction at the close 
of this chapter. At present, we shall consider exclusively the condi- 
tion of the wounded part. 

The third day, often indeed on the second, you may carefully re- 
move the pins of the twisted suture, provided you have also applied 
interrupted sutures ; this is best done by seizing the needle with 
DieffenbacJi } s needle-holder, and rotating it gently, while fixing the 
twisted threads with one finger. The threads usually remain as a 
sort of clamp on the wound, to which they are attached by dried 
blood ; they subsequently loosen spontaneously ; by forcibly detach- 
ing the thread, you would unnecessarily strain the wound, and possi- 
bly tear apart the freshly-united edges. If at this time we carefully 
feel the edges of the wound — if the oedema has subsided — we find them 
rather firmer than parts around ; this state of firm infiltration sooner 
or later disappears. 

"When you have applied many stitches, you may remove some of 
them, that have little to hold, on the third day ; others, on the fourth 
and fifth. At the tensely-stretched parts of the skin it is well to leave 
a few threads for eight days or more, or even leave them till they cut 
through the flaps of the w T ound, provided it can do any good to hold 
together the edges of the wound, which may be gaping open. Should 
the inflammation quickly exceed the normal amount, we must remove 
the sutures earlier, so that they may not increase the irritation ; not 
unfrequently blood, that is decomposing or mixed with pus, at the 
bottom of the wound, is the cause of the unusual irritation. 

In removing the interrupted suture, you should take the following 
precautions : cut the thread on one side of the knot, where you can 
most readily introduce the thin blade of the scissors without stretching 
the wound ; then seize the thread at the knot with a dissecting for- 
ceps, and draw it out toward the side where it was divided, so as not 
to separate the edges of the wound by the traction. 

Should you think that, after removing the suture, the union of tne 
wound is still too weak to prevent its gaping, you may, by applying 
strips of ichthyocolla-plaster transversely over the wound, between the 
points where the sutures were, and fastening the ends (not the part 



UNION OF WOUNDS. 49 

over the wound) with collodion, give support enough to prevent ten- 
sion of the flaps of the wound, such as unavoidably occurs in changes 
of expression in the face. 

In from six to eight days, most simple incised wounds have adhered 
firmly enough to require no further support ; indeed, in many cases, 
this is the case by the second or fourth day. If, in the course of the 
following days, the dry blood about the wound be carefully washed 
off, the young cicatrix appears as a fine red stripe, a scarcely visible 
fine line. This process of healing is called healing by first intention. 

In the course of the subsequent months, the cicatrix loses its red- 
ness and hardness, and finally becomes perceptibly whiter than, and as 
soft as, the skin ; so that for years it may be recognized as a fine white 
line. It often disappears almost entirely after some years. Some of 
you, wno left the university with many still visible cicatrices on the 
face, may hope that they will be scarcely visible in six or eight years, 
when the Philistine visage will become you less than it does the stu- 
dent. Tempora mutantur et nos mutamur in illis. 



LECTURE Y. 

The more Minute Changes in Healing by the First Intention. — Dilatation of Vessels in 
the Vicinity of the Wound. — Fluxion. — Different Views regarding the Causes of 
Fluxion. 

Gentlemen : You are now acquainted with the changes, visible to 
the naked eye, that take place in the wound while it is healing ; let 
us now try to see what occurs in the tissues from the time of wound- 
ing till the formation of the cicatrix. For a long time, attempts have 
been made to study and know these changes more thoroughly, by 
making wounds in animals, and examining them at the different 
stages ; but it is only the most exact microscopic examination of the 
tissue, and the direct observation of the changes after wounding, that 
have enabled us to give a description of the process of healing. I 
shall attempt to give you a brief resume of the result of these investi- 
gations, which, until recently, I have made my special study. 

The interesting results thus arrived at have in a great measure 

brought it about that by " inflammation " we now mean generally the 

series of changes which we perceive on microscopic examination. Of 

late we are accustomed to consider these morphological processes as 

4 



50 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

the essential part of the inflammation, and to term their occurrence 
and typical course the " inflammatory process." I would not weaken 
your interest in these things at the outset ; but the prevailing tenden- 
cies render it necessary for me to call your attention to the fact that 
(as in all organic growth, and in each transformation of the tissues 
of the body) form is always the product of chemical or physical 
power inherent in the material supplied; the inflammatory, like 
every other physiological process, is chemico-physiological ; this we 
never see, even with the best microscopes ; we merely perceive the 
results of its action. These results, destruction and new formation of 
tissue, have something peculiar in their typical course ; but they vary 
as widely as life and death ; the tissue may die suddenly or not for 
years ; of two neoplasia of the same structure, one may form in a few 
days, the other may require months ; very different causes may induce 
very similar new formations. But I dread confusing you, if I enter 
further into the difficulties always arising when we speak of inflam- 
mation in general. So let me go at once into detail ; and we will 
hereafter return to the general question of inflammation. 

The changes after injury of the different tissues are particularly 
seen in the vessels, in the injured tissue itself, and in its nerves. The 
influence of the latter on the process is, however, so obscure, that we 
shall not consider it. We shall at once dismiss as unanswerable the 
question, whether the finest nutrient (vasomotor) nerves, which lose 
themselves in the different tissues (for the question can only arise con- 
cerning these), have any direct influence on the changes occurring in 
the tissues, and in the vessels themselves ; and the rather so, as the 
ends of the nerves have only been certainly recognized in a few parts 
of the body, while for other parts it is entirely unknown how the nu- 
trient nerves act, and what relation they have to the capillary vessels. 
You will have already had your attention called to the imaginable pos- 
sibilities and probabilities on this point, in the lectures on physiology 
and general pathology. Hence, if we say but little about the nerves 
in what follows, it is because we know little of their action in this 
special process, not because we wish to deny their influence. 

Let us first consider the simplest tissue ; let us suppose a vertical 
section, through the connective tissue, with a closed capillary system 
at the surface of the skin, magnified 300-400 times. Here you have 
a diagram of such a system. 

Let there be an incision down through the tissue ; the capillaries 
bleed, the bleeding soon ceases, the wound is accurately united. Now 
what takes place ? 

The blood coagulates in the capillaries as far as the next branches, 



UNION OF WOUNDS. 



51 



to the next points of intersection of the capillary net-work. Some co- 
agulated blood usually remains also between the flaps of the wound; 



Fig. 1. 




Diagram of connective tissue, with capillaries. Magnified 300-400. 



we have omitted this in Fig. 2, so as to have the simplest possible rep- 
resentation of the changes. Of the channels for the circulation in our 
diagram, some have become impassable ; the blood must accommodate 
itself to the existing by-paths — of course this takes place under a 
heavier arterial pressure than previously ; this pressure is greater the 
greater the obstruction to the circulation, and the less numerous the 
by-paths (of the so-called collateral circulation). The result of this 
increased pressure is the distention of the vessels (which, however, is 
usually much greater than could be represented in the diagram), hence 
the redness about the wound, and to some extent also the swelling. 
But the latter also has another cause : the more the capillary walls 
are distended, the thinner they become ; if under the ordinary press- 
ure, with normal thickness of their walls, they permit blood plasma 
to pass to nourish the tissues, now under increased pressure, more 
plasma than normal will pass through the walls, which saturates 



52 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 
Fig. 2. 




Diagram of incision. 



-Capillaries closed by blood-clot Collateral distention, 
nified 300-400. 



Mag- 



the injured tissue, and which the latter absorbs by its power of 
swelling. 

This is a brief explanation of the perceptible changes in the 
borders of the wound, the redness and increased heat caused by the 
rapid development of the collateral circulation, by which more blood 
flows through the vessels nearer the surface ; the swelling is caused 
by the distention of the vessels and swelling of the tissues, which 
again induces slight compression of the nerves, and this excites some 
pain. 

This, as it seems to me, very simple mechanical explanation, would 
be much more valuable, if it fully explained the whole subsequent 
course, and could be applied to all inflammations, which are not of 
traumatic or mechanical origin. But this is not the case. Neither 
the great vascular distention that occurs some time after injury, that 
shows itself in extensive redness around the wound, nor the capillary 
dilatation that exists from the first in idiopathic inflammations, can be 
referred to purely mechanical causes. 



UNION OF WOUNDS— IRRITATION. 53 

If the disturbance of circulation through the incision be not ex- 
tensive, it passes off very rapidly ; these so-called passive hyperemias 
are not exactly inflammations ; their extent accurately corresponds to 
the mechanical conditions, while in regular inflammations the redness 
often extends far beyond the point where the circulation is mechani- 
cally impaired. We do not call it inflammation till irritation of the 
tissues accompanies, or in fact arises from, the capillary distention. 
Such irritations, causing dilatation of the capillaries, are numerous ; 
we shall here speak only of the mechanical ones. You now see my 
ocular conjunctiva of a pure bluish white, like that of any normal eye. 
Now I rub my eye till it weeps, and the conjunctiva becomes reddish ; 
perhaps with the naked eye you may see some of the larger vessels 
— with a lens you will also see the finer vessels, full of blood. After 
five minutes at most, the redness has entirely disappeared. Look at 
an eye where a small insect has accidentally gotten under the lid, as 
so often happens ; the person rubs, the eye weeps and becomes quite 
red ; if the insect be removed, in half an hour you will probably see 
nothing noticeable about the eye. Here you have the simplest obser- 
vation how vessels dilate on irritation, and empty again soon after 
the cessation of the irritation. What is the immediate cause of this 
symptom ? Why do not the vessels contract instead of dilating ? 
These questions are as difficult to answer as the observation is easy 
to make, and to repeat innumerable times, with the same result. The 
fact itself has been known as long as man has observed ; the old say- 
ing " ubi stimulus ibi affluxus " refers to this. The increased flow of 
blood is the answer of the vascular part to the irritation. 

Of late, the process inducing this redness is called active hy- 
permmia or active congestion. Virchow took up the old name, and 
made "fluxion and congestion " again popular. 

Assisted by your knowledge of general pathology, you will now 
perceive that it is desirable to give a theoretical explanation of 
symptoms which, through all time, have formed one of the most im- 
portant objects of consideration in medicine, particularly as the pro- 
cess of inflammation is always considered as closely allied to this ac- 
tive congestion, or indeed even considered as always a sequent of the 
latter. Astley Cooper, a celebrated English surgeon, whose works 
you will read with pleasure, when you take up the study of mono- 
graphs, a thoroughly practical surgeon, begins his lectures on sur- 
gery in the following words: "The subject of this evening's lec- 
ture is irritation ; which, being the foundation of surgical science, you 
must carefully study, and clearly understand, before you can expect to 
know the principles of your profession, or be qualified to practise it 
creditably to yourselves, or with advantage to those who may place 
themselves under your care.'" 



54 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

This will show you what part the questions to-day under con- 
sideration, which you might regard as a superfluous exercise of the 
mind and imagination, have played at various times ; you will here- 
after learn, from the history of medicine, that entire systems of medi- 
cine, of the greatest practical importance, are based on hypotheses 
that were formed for the explanation of this symptom in the vessels, 
of this irritability and of irritability of the tissues generally. 

This is not the place to enter into a thorough historical considera- 
tion of this question ; I will only call to mind a few hypotheses which 
have been advanced lately, under the already-existing knowledge of 
the vessels and parts visible to the naked eye, concerning the occur- 
rence of vascular dilatation from irritation. 

From histology and physiology, you know that, until they pass 
into capillaries, the arteries and veins have transverse and longitudi- 
nal muscular fibres in their walls, and that in general these are more 
scanty in veins than in arteries, although this varies greatly. Now, 
although it may be very difficult to make direct observations of the 
effect of irritation on these smallest arteries and veins, it is very simple 
to see its effect in the intestine, where we have essentially the same 
conditions, namely, a tube provided with longitudinal and transverse 
muscular fibres. But, irritate the intestine as you may, you will never 
induce dilatation at the constricted part, but only a shortening or con- 
striction and a consequent motion of the contents of the intestine, 
whose rapidity will depend on the frequency of the repetition of the 
contractions. But can dilatation of the capillaries be induced by such 
increased rapidity of motion of the vessels and blood ? Certainly not. 
In the general pathology of Xotze, the celebrated medical philosopher 
of Gottingen, you find some remarks which are so apt, and, like all the 
chapters on this subject, so well show the brilliant genius and critical 
acumen of the writer, that I shall make use of his expressions. He 
says : " Pathologists who seek to explain congestion by increased con- 
traction of the arteries, assume the thankless task of the Danaides; 
they cannot show the stopper that prevents the escape of the blood 
that is pumpel in with so much difficulty. Over-fulness results if 
more is introduced and the same amount escapes, or if the same 
quantity is introduced but less escapes. If we suppose a portion of a 
vessel to contract more actively and rapidly, it will have as little ten- 
dency to induce increased afflux or diminished efflux of blood as the 
stamping of a person in a river would to regulate the amount of 
water." 

This refuted hypothesis, of the dilatation of the capillaries depend- 
ing on more rapid and energetic contraction of the arteries, was ai 
least based on known observations ; but Lotze's explanation, on the 
contrary, is so far from all analogy, I might almost say so metaphysi- 



UNION OF WOUNDS— IRRITATION. 55 

eal, that we cannot attach any value to it. Lotze asserts that there is 
no objection to the supposition that capillaries are affected differently 
from arteries by irritation ; by nervous influence they may expand ac- 
tively on irritation, by their molecules separating. But this view is 
pure hypothesis, which not only has no analogy, but is even opposed 
to recent observations. It is well known that, with the microscope, 
we can follow the circulation in the smaller arteries and veins, as well 
as in the capillaries of the web in the foot, in the mesentery and 
tongue of the frog, or in the wing of a bat ; but the immediate effect 
of a mild chemical or mechanical irritant does not at once show in the 
capillaries, but first in contraction of the smaller arteries, occasionally 
also of the veins ; this is very evanescent, of scarcely a second's dura- 
tion, indeed, it often escapes observation, and we then suppose that 
its duration and grade are too slight for us to measure. This brief 
contraction is followed by the dilatation, whose immediate cause is 
indistinct even on microscopical observation. We shall soon see that 
this is insufficient, that the fluxion is the result of paralysis of the ves- 
sels, active as the symptom appears. Even the recent very interest- 
ing observations of Golubew, who had the kindness to show me that 
the capillaries of the nictitating membrane of the frog contract trans- 
versely, as the result of strong electrical shocks, did not appear to me, 
on thinking the matter over, to apply perfectly to the question of 
fluxion. 

Vzrchow appears to think that the irritation, which is certainly the 
immediate cause of the contraction, is followed by quick fatigue of 
the muscles of the vessels ; that after a tetanic contraction there is a 
relaxation, just as in irritated nerves and muscles — a view which 
may find some support in a communication from Dubois-JReymond 
about the painful tetanus of the muscles of the vessels in the head as 
a cause of headache on one side, so-called hemicrania, since this sup- 
posed tetanus of the muscles of the vessels, induced by strong excite- 
ment of the cervical portion of the sympathetic, was certainly followed 
by their relaxation and great distention of the vessels, and shortly by 
symptoms of cerebral congestion. 

But, in this view (by which a relaxation or temporary paralysis of 
the walls of the vessels and a consequent decrease of their resistance 
to the pressure of the blood would, it is true, be explained as a se- 
quent of their contraction), we must not forget that it is by no means 
proved that the muscles of the vessels, once irritated and excited to 
rapid contraction, are indeed paralyzed, while in other muscles this 
fatigue usually occurs only after repeated irritation. It is necessary 
arbitrarily to assume that the muscles of the vessels very readily be- 
come fatigued, which is directly refuted by experiment. From physi- 



56 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

ology you know that Claude Bernard has proved that the contrac- 
tions and dilatations of the arteries of the head are under the influ- 
ence of the cervical portion of the sympathetic nerve, as I have al- 
ready indicated. If we irritate the upper cervical ganglion of this 
nerve, the arteries contract ; if we divide the nerve, there is dilatation 
(paralysis) of the arteries and capillaries. This experiment of irri- 
tating the muscles of the vessels may be often repeated, without their 
becoming quickly fatigued, unless the electrical current be too strong ; 
hence we might imagine that there is little probability in the hypoth- 
esis of immediate fatigue after a single irritation. Schiff, however, 
like Lotze, assumes that active dilatation of the vessels is possible ; he 
thinks that this necessarily follows from certain experiments ; but 
this is perfectly incomprehensible to me, for there are no muscles that 
could actively dilate the vessels. 

If the veins alone contracted on being irritated, filling of the cap- 
illaries would doubtless follow the obstruction, and there would then 
be no difference between venous (passive) hyperaemia and fluxion. 
But this supposition is quite untenable ; it is perfectly incomprehensi- 
ble that the veins alone should contract on inflammatory irritation. 
That the veins contract on mechanical irritation, you may see in the 
femoral vein of an amputated thigh, to which Virchow has called 
particular attention, and this irritability lasts even longer in the walls 
of the vein than in the nerves. 

Herile already advanced the view that the symptom of distention 
of the vessels from irritation was directly caused by paralysis of their 
walls ; when JOotze, in opposition to this, says that it is not supposable 
that there should be paralysis of the muscles in a man who is exces- 
sively irritated and has his muscles tense and his face glowing, his 
objection is not perfectly tenable. Nor does the other objection of 
the usually acute Lotze appear to me correct when he says, " What 
shall we think of paleness, of the contraction of the vessels that results 
from fright and terror ? Does that look as if due to great muscular 
action, if redness in anger and shame is induced by paralysis ? " I say 
this proves nothing. Fright may throw the muscles into a tetanic 
state, which is usually quickly followed by fatigue of the muscles of 
the vessels ; immediately after a great fright, we generally feel the 
blood pour into the cheeks, as soon as we begin to breathe and re- 
cover from the shock ; we soon grow red again, at first indeed redder 
than we often like ; not un frequently the paling from fright is often 
overlooked, and only the succeeding redness perceived. 

Still, apart from these objections, how can we imagine the paralyz- 
ing action of an irritated nerve ? We actually know such phenomena 
from physiology ; the obstruction of the heart's action by irritation of 



UNION OF WOUNDS—IRRITATION. 57 

the vagus nerve, of the movements of the intestines from irritation of 
the splanchnic nerve, etc. Here a vaso-motor nerve-system is sup- 
posed which arrests the contraction of the muscles ; could not such a 
vaso-motor nerve-system also be supposed for the vessels — nerves, 
irritation of which lessens the tone of the muscles of the vessels and 
thus renders the walls less capable of resisting the pressure of blood ? 
The doctrine about vaso-motor nerves is so difficult to explain, that 
even a brief exposition of the probable possibilities of the process 
would lead us too far ; hence I must content myself with having called 
attention to the analogous physiological processes. ~Virchow and 
Henle agree in the view that the symptoms of fluxion are due to 
paralysis of the vessels, although they refer this paralysis to different 
causes ; on the whole, most credence is attached to the view that the 
muscles of the vessels, like those of the heart, are partly under the 
influence of sympathetic, partly of cerebro-spinal nerves, and that the 
former cause the rhythmical (automatic) contractions of the vessels, and 
the latter act as regulators or obstructors of these contractions. Irri- 
tation of the sympathetic filaments would increase the contractions 
of the vessels, dividing them would result in paralysis of the mus- 
cles of the vessels and their consequent dilatation ; but the latter 
might also be caused by irritation of the cerebro-spinal obstructive 
nerves. 

The discovery by A.eby, JEberth, and Auerbach, that the blood- 
capillaries are entirely composed of cells, might excite new hypotheses 
about the irritability of the capillary cells and their influence on dila- 
tation and contraction of the capillaries, although even this would 
not solve the mechanical difficulty which opposes the idea of an active 
vascular dilatation. In the action of local irritation and entirely 
local dilatation of the vessels we have the choice of considering that 
irritation of the nerves of the vessels (or of the living cell-substance 
of the capillary walls) directly disturbs their function, or that this dis- 
turbance is due to reflex irritation. 5 

You have now material enough for meditation. None of the 
hypotheses advanced can claim to fully explain the symptoms of 
fluxion, although some of them perhaps contain the germ for future 
perfect development. Still the recognition of this truth, the dis- 
tinction of hypotheses from observation, is useful ; it does not limit 
the onward progress of experiment, but constantly reanimates it. 
Congratulate yourselves that it is permitted to you and the coming 
generation to clear up this point. 

We shall now leave this question, and the next hour shall again 
return to the field of certain observation, to study the effect of the 
wounding 1 on the tissue itself. 



58 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



LECTURE VI. 

Changes m the Tissue during Healing by the First Intention. — Plastic Infiltration.— 
Inflammatory New Formation. — Eetrogression to the Cicatrix. — Anatomical Evi- 
dences of Inflammation. — Conditions under which Healing by First Intention does 
not occur. — Union of Parts that have been completely separated. 

The dilatation of the capillaries and the exudation of blood-serum 
that usually accompanies it, which we have found as the first effect of 
the wound, and which is most readily seen in the living tissue, as 
above mentioned, cannot of course by itself cause two flaps that are 
brought in apposition to unite organically — changes must take place 
on the surfaces of the wound, by which the latter are to a certain ex- 
tent dissolved and melted into each other ; just as you render two ends 
of sealing-wax soft by heat, to fasten them together, so here the sub- 
stance itself must become the means of union, in order that it should 
be firm and intimate. In fact, this is the final result of the healing 
process, both in the soft parts and in the bone. 

Let us keep in mind the above diagram (Fig. 2), and suppose that 
only connective tissue and vessels have been wounded, and that their 
reunion is the question for consideration. As you already know, con- 
nective tissue consists of cellular elements and filamentary intercellular 
substance. The cellular elements are partly the stable, fixed, long- 
known connective-tissue corpuscles, i. e., flat, nucleated cells, with long 
processes, which adhere to the connective-tissue bundles, partly the 
wandering cells discovered by Recklinghausen, which are identical 
with white-blood and lymph cells, in form, species, and vital peculiar- 
ities, are probably formed for the most part in the lymphatic glands, 
through the lymphatics enter the blood, from the capillaries and veins, 
occasionally wander into the surrounding tissue (as discovered by 
Strieker), there become fixed tissue-cells, or again (as observed by 
Hering) enter the lymphatic or blood vessels, or undergo metamor- 
phoses not yet discovered. 

If we examine the tissue of the flaps of the wound a few hours 
after the injury, we shall find it full of wandering cells. These in- 
crease enormously from hour to hour ; they infiltrate the fibrous tissue, 
already softened by swelling, and even wander from one flap of the 
wound to the other. During this cell-activity, and probably on ac- 
count of it, the connective-tissue intercellular substance gradually 
changes to a homogeneous gelatinous substance, which gradually disap- 
pears as the cells increase, possibly being consumed by them ; so that 
there is a time when the surfaces of the wound in apposition consist 



PLASTIC INFILTRATION. 



59 



almost entirely of cells, held together by a very slight quantity of 
gelatinous intermediate substance (which subsequently becomes firmer 
and finally fibrous). 

In the sketch below (Fig. 3), a sequel to the above diagram, you 




Diagram representing the surface of the wound united by inflammatory new formation. 
a, plastic infiltration of tissue. Magnified 300-400. 



see a section of the wound now united by newly-formed tissue, which 
once for all we shall term inflammatory new formation or primary 
cellular tissue. Virchow calls it granulation tissue, Hindfleisch germ- 
tissue. The inflammatory new formation results from an earlier state 
in which the still filamentary connective tissue is infiltrated with innu- 
merable wandering cells, a state which may readily return to the nor- 
mal by atrophy of these cells. This stage of cellular or plastic infiltra- 
tion, in which the tissue feels firmer than in watery edematous infiltra- 
tion, is almost always at some distance from the edge of the wound, 
so that in any such specimen of a recent wound we may follow the 
development of the inflammatory new formation from the plastic 
(cellular) infiltration, if we make microscopical examinations from the 



60 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



normal tissue toward the wound. The injury represents an inflamma- 
tory irritation, whose action may extend somewhat beyond the im- 
mediate vicinity of the irritation, but then rapidly diminishes. 



Fig. 3 a. 




Vein and capillary vessel from the mesentery of a frog, which has lain exposed for some hours. Eed 
blood-cells from the circulation ; white blood -cells lying against the walls and wandering into the 
loose connective tissue of the mesentery. Magnified about S00 diameters. 

In the great majority of cases there will be at least a slight layer 
of coagulated blood between the flaps of the wound ; this also extends 
somewhat into the interstices of the tissue of the flaps of the wound. 
This blood-clot may sometimes interfere with the healing, as when, 
from its size or other casues, it decomposes or turns to pus ; but it may 
also become cicatricial tissue and perfectly disappear with the new 
formation in the flaps of the wound ; this must take place for union 
by the first intention to occur. We shall hereafter speak of the 
changes that take place in the clotted blood during this process. 

We must now attend to the question, Whence come the innumera- 
ble wandering cells that infiltrate all inflamed tissues immediately after 



PLASTIC INFILTRATION. 



61 



their irritation, as they here do the flaps of the wound? Of late, this 
question has received the following wonderful explanation, which ten 
years ago would have been considered as the fancy of a madman. 
Cohnheim made the following remarkable observation : he introduced 
finely-powdered anilin blue into the lymph-sac in the back of a frog, 
then irritated the animal's cornea with caustic, and found that numbers 
of wandering cells (lymph-pus cells) containing anilin gradually col- 
lected at the cauterized point ; hence the conclusion, at an irritated 
point white blood-corpuscles wander from the vessels into the tissue ; 
these white blood-corpuscles constitute the inflammatory cellular in- 
filtration. Cohnheim then confirmed, by direct observation on the 
mesentery of a living frog, the discovery already made by Strieker on 
the nictitating membrane that had just been removed, that under 
some circumstances the white blood-cells wander through the walls 
of the vessels into the tissues, and showed also that this occurred to 
a still greater extent in dilated capillaries and veins. 

Although it was afterward shown that an English experimenter, 
Aug. Waller, had several years previously made similar observations 
on the mesentery of the toad and the frog's tongue, the works of 
the German observers, Strieker, Von Recklinghausen, and Cohnheim, 
were quite independent of his, and Cohnheim has the undivided 
honor of having correctly interpreted his observations on inflam- 
mation, which have constantly advanced to the present time, and 
of having presented them in a form to greatly affect all modern 
pathology. 

It is difficult for you, gentlemen, to imagine the immense impression 
made on all histology by these new discoveries, which I have just 
imparted to you as simple facts, because you are not acquainted with 
the former point of view from which the origin of inflammatory new 
formations, and that of complicated organized growths, was regarded. 
From previous observation, our idea of the affair was about as follows : 
It was supposed that the cells of the connective tissue, of which only 
one variety, the fixed, was known, increased greatly by division as a 
result of irritation, and cellular infiltration thus resulted. Imagine 
yourselves back a few years, in a time when nothing was known of the 
vital peculiarities of young cells, of their amoeboid and locomotor ac- 
tion, and we only knew how to deduce the course of the pathological 
process from various stages of the diseased but not dead tissues, as is 
still the case in the normally-developing layer ; then you will readily 
understand that it was decided without hesitation that the cells tying 
packed together in the inflamed tissue were formed out of one an- 
other. Even this was a great advance, which was only possible after 
the overthrow of the generatio mquivoca / for, not long before, the 



62 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

development of cells and tissue from lymph, coagulated blood, and 
fibrine, was firmly believed in. The first observations on cell-division 
as a result of abnormal irritation were made on cartilage by Redfern in 
England : then followed the observations of Virchow and Heis on in- 
flamed cornea. In both cases it was seen that after cauterization with 
nitrate of silver, or after introduction of a seton, the tissue was filled 
with young cells; in the original tissue-cells, biscuit-shaped, then 
double nuclei were seen, from which a division was decided on ; young 
cells were seen grouped together, and their origin from the tissue-cells 
seemed indubitable. Hence arose the idea that inflammation was a 
process in the tissues, which, entirely independent of the vessels, was 
associated with a rapid luxuriant proliferation of tissue-cells, and par- 
tial softening and disintegration of the intercellular tissue. Von 
Recklinghausen 's discovery of the two varieties of cells found in con- 
nective tissue, as well as his discovery of the varied movements of 
pus-cells, might well have given rise to the question whether the pro- 
liferation of the cells, on irritating the tissue, started from the fixed 
or movable connective-tissue corpuscles, but failed to do so. But 
now observation is piled on observation ; and we are driven to the 
supposition that all young cells which in inflammation we find ab- 
normally in the tissue are wandering white blood-cells. 

Observers who have recently investigated this point do not all 
agree ; some still ascribe to the stabile cells of the connective tissue 
a part in the inflammatory process. Strieker, in his latest publica- 
tions, maintains that, on irritation, the stabile tissue-cells are filled 
with neoplasma, increase by segmentation, and aid in the formation 
of pus ; but he does not deny the wandering of white blood-cells. 
Cohnheim, Key, Eberth, and others have denied the correctness of 
Strieker's observations, or rather of his interpretations. Observa- 
tions on this point are so tedious that we cannot wonder at the delay 
in elucidating a question apparently so simple. 

Of course, from the various errors to which we are liable in inter- 
preting the significance of what has been observed, we should be very 
careful about announcing general principles. In regard to the in- 
flammatory changes in connective tissue, however, as far as my obser- 
vation and criticism extend, I would maintain the above statements. 

In cartilage alone, nothing has been observed different from for- 
mer appearances. As the hyaline cartilage-substance has no canals 
passable for cells, so far as we at present know, there is little left 
except to suppose that the increase of cells in the cartilage-cavities 
after irritation results from division of the protoplasm of the cartilage- 
cells ; of this I shall hereafter show you preparations ; still hyaline 
cartilage has never yet been watched for days in a living and irri- 



PLASTIC INFILTRATION. 63 

tated state, and consequently this observation must give place to 
the studies on living connective tissue. 

But in hyaline cartilage there is no such acute suppuration or 
infiltration of pus as in connective tissue. I will again repeat that I 
only consider a renovation and proliferation of connective tissue and 
corneal cells as improbable in those cases where the protoplasm has 
been entirely metamorphosed even to the nucleus, that is, the sta- 
bile connective tissue and corneal granules of grown animals whose 
tissues resemble those of man. It has never been doubted that pro- 
toplasm, when it exists as such in cells, that is, in growing tissues of 
young individuals, may increase and divide up ; inattention to these 
points may have given rise to some of the differences in the views 
above stated. The same is true of epithelial tissues ; it has never 
been maintained that the cells of fully-developed epithelial tissue, 
the elements of the hair, nails, epidermis, and upper layer of flat 
epithelium, could be renovated by irritation, while it is not denied 
that constant increase of the young elements of these tissues is a 
physiological necessity for their growth ; here the only difference is 
that growth of these epithelial tissues continues during life, while 
that of connective tissues only goes on to a certain age, and hence, 
after cessation of the growth, wandering cells are the only young 
elements found in these tissues. 

If it be now established beyond doubt that most of the young 
cells which infiltrate the inflamed tissue and sometimes escape from 
it as pus, as we shall hereafter see, are white blood-cells, or briefly 
wandering cells, then two questions arise : Why do so many cells 
wander into inflamed tissue ? How do such numbers of them get 
into the blood, and whence do they come ? There are different 
views as to the mode of escape of wandering cells through the walls 
of vessels. 

My views are as follows : The first change that we see in inflamed 
tissues during life is dilatation of the vessels ; the immediate result 
of this is increased transudation and a collection of white blood-cells 
along the periphery of the vessel. Then the wall of the vessel is 
gradually softened by some unexplained chemical process that goes 
on in every inflammation, so that by their active movements the 
white blood-cells gradually enter and finally pass through it. Hence 
dilatation of the vessels, accumulation of white cells along the walls 
of the vessels, and softening of the walls, seem to me to be the 
requirements for extensive emigration of cells. Cohnhelm and 
Samuel have lately announced the same opinion. Whence come the 
immense number of white blood-cells that escape in inflammation is 
entirely a physiological question. The lymphatic glands and the 



64 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

spleen are the organs which we first suspect ; and, although it can- 
not be proved that numerous new lymph-cells are formed as the 
others escape, it is very probable, especially as we know from clini- 
cal experience that the lymphatic glands in the vicinity of an inflam- 
mation almost always swell. In spite of careful search, I have been 
unable to discover any thing about the morphological process of this 
cell-formation, but consider it very probable that lymph-cells origi- 
nate from sprouting of the nets of the lymph-sinuses in the glands. 

I must mention one other point, which is, that in inflammation red 
blood-corpuscles also not unfrequently pass through the walls of the 
vessels ; according to Cohnheim's experiments, this is greatly influ- 
enced by the increased intravascular pressure. 

According to Arnold, not only red but white blood-cells escape 
from the walls of the vessels at points where the capillary vessels 
leave small openings (stigmata, stomata) ; it is said to be more es- 
pecially the cement of the cells of the capillary vessels that swells on 
inflaming, and becomes so yielding that fine streams of blood-serum 
flow through these vessels into the interstices of the tissues. 

Let us now return to our wound, and see what becomes of the tis- 
sue infiltrated with cells, of the inflammatory new formation ; how the 
cicatrix develops from it while the cell-infiltration extends slowly and 
sluggishly at some distance from the wound. The cells in the surfaces 
of the wound, which already adhere loosely, gradually assume a spin- 
dle shape ; the intercellular tissue then becomes firmer, the spindle- 
cells change to fixed connective-tissue cells, and finally the young 
cicatricial tissue assumes more and more the form of normal, fibrous 
connective tissue ; that is, the white blood-cells become fixed connec- 
tive-tissue cells, as probably takes place even in the embryo. Here, 
again, we are met by various questions. The newly-formed adhesive, 
interlacing tissue soon becomes firm, especially in healing by the first 
intention ; even after twenty -four hours we find its intercellular sub- 
stance quite stiff and fibrinous, and the borders of the wound are also 
more or less infiltrated with this stiff substance ; it is only the early 
hardening of the intercellular connective substance, formed of trans- 
uded serum and softened connective tissue, that explains why the 
union is so firm, even the third day, that the flaps of the wound hold 
together without sutures, for without such connective substance the 
young cellular tissue could not be so coherent. This stiffening con- 
nective-tissue substance (Fig. 8) is most probably fibrine, which con- 
sists of the transudation coming from the vessels under the influence 
of the extravasated blood-corpuscles, possibly also of the wandering 
cells. From the excellent experiments of Alexander Schmidt it is 
known that most exudations contain the so-called fibrogenous sub- 



HEALING BY FIRST INTENTION. 65 

stance, which forms fibrine as we know it in the coagulated state, by 
combining with the fibro-plastic substance of the blood and other tis- 
sues. Very accurate proportions of fibrogenous and fibrino-plastic 
substance are required to form fibrine ; these favorable requirements 
occur in many inflammations. Schmidt considers it probable that 
all firm fibrous tissue is formed and maintained by the fibrogenous 
substance from the blood being precipitated in a certain manner 
around the tissue-cells, because they contain a fibrino-plastic sub- 
stance in a firm shape. Under this hypothesis we racist suppose a 
specific cell-action, which would cause the coagulating product to as- 
sume the form of muscular strise in one place and in another of con- 
nective tissue. In our case this is a very probable view, for we see 
filamentary connective tissue gradually form from the intercellular 
coagulated fibrine. It is true the amount of intercellular substance 
in the new formation is not great, but there is little doubt that the 
small spaces between the cells are filled by it. A short time subse- 
quently the young cicatricial tissue appears still to consist chiefly of 
spindle-cells closely pressed together (Fig. 9) ; but then the spindle- 
cells diminish greatly by flattening, many are even destroyed, and we 
have now a filamentary connective-tissue substance, which is to be 
considered partly as a product of secretion, partly as metamorphosed 
protoplasm of the spindle-cells ; the cicatricial tissue finally remains 
stable in this state. Thiersch, who quite recently has again carefully 
studied the healing of wounds, maintains that the apparently fibri- 
nous intermediate substance is not fibrine, but only metamorphosed 
connective tissue. 

I will not deny that there may be an immediate union of the soft- 
ened edges of the wound, although it must be very rare. Quite 
recently I had Dr. Gussenbauer make a new series of accurate obser- 
vations on healing by the first intention with especial reference to 
Thiersch's views. He could not confirm the latter's observations, but 
he, as well as GuterbocJc, arrived at results which in the main corre- 
spond with the above views, which I arrived at from my own studies. 

Meantime, what has become of the closed ends of the vessels ? 
The blood-clot in them is reabsorbed or organized ; the walls of the 
vessels send out shoots which communicate with the vascular loops of 
the opposing border of the wound, and with each other. In this way, 
however, only the rather scanty union of the opposing vascular loops, 
which is at first slight, is accomplished ; these were already formed by 
extensive tortuosities and windings of the vessels, which had loop- 
shaped terminations after the injury (Figs. 12-14). This is not the 
place to go into the details of this interesting development of the vas- 
cular loops ; their development is not due solely to dilatation, but very 
5 



66 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



FlG> 3 B - much to interstitial growth of 

the walls of the vessels. The 
original, formerly-existing vascu- 
lar union is thus replaced by a 
newly-formed vascular net-work 
which is at first far richer. 

Quite recently Arnold has 
most carefully studied the pro- 
cess of the development of ves- 
sels, and has seen it go on in the 
tails of tadpoles (Fig. 3 b.) 

Although the heart and larger 
vessels of the embryo seem to 
originate from appointed cell- 
groups of the middle germinal 
layer, by the peripheral parts 
forming the wall of the vessel 
and the central parts the blood- 
cells, later this does not seem to 
occur ; at least, observations made 
on this point by RoJcitansky and 
others do not seem to have ob- 
tained much credence. According 
to Arnold' 's investigations, off- 
shoots from the vessels seem to 
be the only mode of development 
of vessels in the embryo. 

I formerly thought that there 
must be another mode of growth 
for vessels in the formation of 
granulations and in some neo- 
plasia, namely, a tubular forma- 
tion by laying together spindle- 
cells, as at a, b, and c, in Fig. 
3 c ; this I called " secondary " 
formation of vessels (" primary " 
I applied to the development of 
the heart and larger vessels in 
the middle germ-layer). The 
development of vessels by off- 
shoots I called " tertiary." But, 
since recent investigations, I 

The course of the formation of these vessels runs readily agree that the mode I 




a, b, e. These changes occurred in 10 hours. 
Magnified 300. After Arnold. 



termed " secondary " possibly did 



HEALING BY FIRST INTENTION. 



67 



not exist, and that the fine plasma string (the offshoot) and the fine tube, 
on which the spindle-cells growing out of the young adventitia lay, 
may have escaped my notice. But I will not neglect to mention that 
Thiersch^ supported by recent observations, has repeated his former 
assertions (which then seemed to me improbable) that in the young 
inflammatory neoplasia there is a net-work of tubes, connected with 
the blood-vessels by stigmata, which is bounded merely by the tissue- 
cells, not by special walls ; this agrees very well with the recent ob- 
servations on capillaries in inflamed tissues. According to this, there 
would be blood-vessels in this tissue which are not circular canals, 
but irregular intercellular passages, perhaps merely bounded by spin- 
dle-cells. 



Fig. 3 o. 




Disposition of vessels in the vitreous body of an embryo calf. Magnified about 600. After Arnold. 

As a result of the restoration of circulation through the young cica- 
trix, the circulatory disturbances caused by the injury are removed, 
the redness and swelling of the borders of the wound disappear ; from 
the numerous vessels, the cicatrix appears as a fine red stripe. Now 



68 SIMPLE INCISED WOUNDS OF THE SOFT PARTS, 

the consolidation of the cicatrix must take place : this is accomplished, 
on the one hand, by the partial disappearance of the newly-formed 
vessels, whose walls fall tog-ether, and they thus become solid, fine, 
connective-tissue strings ; on the other hand, by the intercellular sub- 
stance becoming firmer and containing less water, as above mentioned, 
the cells assume the flat form of connective-tissue corpuscles, or disap- 
pear ; possibly some of them remain as wandering cells, and return 
again into the lymphatics or blood-vessels. To this condensation and 
atrophy is due the great contractile power of the cicatricial tissue, 
by means of which large, broad cicatrices may occasionally be reduced 
to half their original size. 

At the first glance, it might appear to you contradictory, that an 
apparently excessive capillary net-work should be formed in the young 
cicatrix, and should subsequently be for the most part obliterated. We 
cannot explain this apparent excess, still there are plenty of analogies 
in embryonal development ; I only need to remind you that there is a 
period in fcetal development when, even in the vitreous body, there is 
a capillary net-work, which, as you know, disappears, leaving scarcely 
a trace. 

Not to fatigue you with so-called theoretical subjects, I leave this 
field for a short time, and, before leaving healing by the first inten- 
tion, as a point fully understood, I shall make a few remarks on the 
causes that may prevent this mode of healing, even when the flaps of 
the wound are in apposition. 

Healing by first intention does not take place : 1. When the edges 
of the wound are brought together by plasters, or sutures, but their 
tension or tendency to separate again is very great. Under these 
circumstances, either the plasters do not keep the wound accurately 
closed, or the sutures cut through the flaps ; perhaps also the tension 
of the tissues obstructs the flow of blood in the capillaries, and thus 
disturbs the cell development and formation. How great this tension 
must be, and what means we have for relieving it, you can only learn 
in the clinic. 

2. A further obstruction to healing is, a large amount of blood 
poured out between the edges of the wound ; this interferes with the 
process of healing, partly as a foreign body, and partly, if it decom- 
poses, by the influence of the process of decomposition. 

3. Other foreign bodies, as sand, dirt, alkaline urine, faeces, etc., 
also retard the healing, partly mechanically, partly chemically. Hence 
these substances should be carefully removed before uniting the wound. 
In wounds of the urinary bladder, it is not usual to attempt the clos- 
ure of the skin- wound ; the urine would force its way into the sub- 
cutaneous cellular tissue, or into the peritoneal sac, and excite terrible 



HEALING BY FIRST INTENTION. 69 

injury. Here, under some circumstances, it would be a decided fault 
to unite the wound, although of late the views on this particular point 
differ somewhat from those of former days. 

4. Lastly, from a contusion, whose effect on the flaps of the wound 
we may fail to observe, there may have been an extensive disturbance 
of circulation and destruction of minute tissue, which has induced the 
partial death of certain parts or of the whole surface of the wound. 
Then, as there is no cell-formation in the edges of the wound, but only 
where the tissue is still living, we have small tags of the destroyed 
tissue lying as foreign bodies between the edges of the wound ; these 
must prevent healing by first intention. If this mortification attack 
only minute particles, these may possibly quickly undergo molecular 
disintegration and absorption ; this may occur not unfrequently. We 
shall speak more extensively of this mortification of the tissue, and of 
its detachment from the healthy parts, when treating of contusions. 

Experience, arising from many observations in judging of wounded 
surfaces, will hereafter enable you in most cases to say whether heal 
ing by first intention may be expected or not, and you will also learn 
when it may be useful, even in doubtful cases, to try to aid this union 
by applying dressings. 

You will occasionally hear of wonderful cases where parts of the 
body, completely separated, have again become united. This appears 
to be actually the case. I have never had the opportunity of making 
any observations on such cases ; still, even in late days, very trust- 
worthy men have asserted that they have seen small portions of skin 
again unite after being removed from the fingers by a blow or cut, 
then carefully replaced and fastened on with adhesive plaster. For- 
merly I contended against the possibility of this healing, but must now 
admit it, also on theoretical grounds, after it has become imaginable 
that, through the movements of the cells, the detached portions, if not 
too great, may soon be restored to life again by the entrance of wan- 
dering cells. That we may successfully transplant a twig, cut from one 
tree, into another one, is well known ; but, as the circulation in plants 
is not by pumping, but the sap runs simply by cellular force, the anal- 
ogy is not very close ; it was more remarkable, it is true, that a cock's 
spurs could be transplanted to his comb, but between birds and men 
the differences in the formative process are also very great, and any 
immediate transfer of observations is inadmissible in practice. 

When treating of the cicatrization of wounds with loss of sub- 
stance, we shall investigate the discovery of Heverdin that we may 
cause epidermis to grow on granulating surfaces.* 



70 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



LECTURE VII. 

Changes perceptible to the Naked Eye in Wounds with Loss of Substance. — Finer Pro- 
cesses in Healing with Granulation and Suppuration. — Pus. — Cicatrization. — Ob- 
servations on "Inflammation." — Demonstration of Preparations illustrative of the 
Healing of Wounds. 

It now remains for us to inquire what becomes of the wound, if, 
under the above circumstances, it does not heal by first intention. 
Then, as the flaps gape, we have an open wound before us ; and 
the circumstances are the same as if the gaping wound had not been 
closed, or as if a piece had been cut out, as in a wound with loss of 
substance. Accurate observation of such wounds, which are usually 
covered with some unirritating body, as with a fold of linen dipped in 
oil, with oiled or dry eharpie, etc., shows the following changes — if we 
examine it daily, this is not necessary, it is true, and may even be in- 
jurious : after twenty-four hours, you find the borders of the wound 
slightly reddened, somewhat swollen, and sensitive to the touch ; the 
same symptoms as in closed wounds. As in healing by first inten- 
tion, these symptoms may be very insignificant or entirely absent, as 
in old, relaxed, flabby skin, also in strong skin with thick epidermis. 
We observe these symptoms best in the skin of healthy children. An 
extensive and increasing redness, swelling, and pain about the wound, 
make us suspect an abnormal course ; just as, with the same symptoms 
in a wound healing by first intention, various individual circumstances 
are to be considered, and the vibrations from the normal to the abnor- 
mal are so numerous, that the dividing line is often difficult to deter- 
mine. After the first twenty-four hours, the surface of the wound has 
changed but little ; all over it you can still recognize the tissues quite 
distinctly, although they have a peculiar gelatinous, grayish appear- 
ance ; you also find a considerable number of yellowish or grayish-red 
small particles over the surface ; on close examination, you find these 
to be small fragments of dead tissue, which still adhere, however. The 
second day, you may already notice a trace of reddish-yellow, thin 
fluid over the wound, the tissues appear more regularly grayish red 
and gelatinous, and their boundaries become more indistinct. The 
third day, the secretion from the wound is pure yellow, somewhat 
thicker, most of the yellow dead particles are detached and flow off 
with the secretion ; the surface of the wound becomes more even and 
regularly red — it cleans off", as we say technically. If you had not 
bound up the wound (a stump from amputation, for instance), and had 
received in a basin the secretion that formed, the first and second day 
you would find it bloody, brownish red, then of a gelatinous dirty gray, 



HEALING BY GRANULATIONS. 7! 

then dirty yellow : at the points where the secretion flows from the 
wound, fibrine not unfrequently stiffens in drops. If you examine care- 
fully with a lens, even the third day, you will see numerous red nod 
ules, scarcely as large as a millet-seed, projecting from the tissue 
— small granules, granulations, fleshy warts. By the fourth or sixth 
day these have greatly developed, and gradually join into a fine, granu- 
lar, bright-red surface — the granulating surface / at the same time, the 
fluid flowing from this surface becomes thicker, pure yellow, and 
of creamy consistence ; this fluid is pus, and, when of the quality here 
described, it is good pus, pus bonum et laudabile of old authors. 

Of this normal course there are many varieties, which chiefly de- 
pend on the parts injured, and the mode of injury ; if large shreds of 
tissue from the surface of the wound die, the wound is longer in clean- 
ing off, and then you may sometimes see the white, adherent shreds of 
dead tissues still clinging for days to the surface, most of which is al- 
ready granulating. Tendons and fasciae are particularly apt to have 
their circulation so impaired, even by simple incised wounds, that they 
die to an unexpected extent from the cut surface, while there is little 
loss of loose cellular tissue or muscle. This is undoubtedly due partly 
to deficient vascularity of the tendinous parts, partly to their firm- 
ness, which does not permit rapid collateral dilatation of the vessels ; the 
same is true in injuries of bone, especially of the cortical substance, 
where there is often death of the injured bone-surface, that requires 
a long time for detachment. Other obstacles to active development 
of granulations are constitutional conditions; for instance, in very 
old or debilitated persons, or badly-nourished children, the develop- 
ment of granulations will not only be very slow, but they will look very 
pale and flabby. Hereafter, at the close of this chapter, I will give 
you a short review of those anomalies of granulation which are daily 
occurrences in large wounds, and, to a certain extent, may be regarded 
as normal or at least customary. 

But, to return to the observation of the normally- developing layer 
of granulations, with the continued secretion of pus, you perceive 
that the granulations become more and more elevated, and sooner or 
later attain the level of the skin, and not unfrequently rise above it. 
With this process of growth, the individual granules become thicker, 
and more confluent, so that they can hardly be recognized as separate 
nodules ; but the entire surface assumes a glassy, gelatinous appearance. 
Occasionally the granulations remain for a long time at this stage, 
so that we have to use various remedies to restrain the proliferating 
neoplasm within bounds that are requisite for recovery; on the 
periphery, particularly, the granulations should not rise above the 
level of the skin, for the cicatrization has to commence at this point. 



72 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

The following metamorphoses now gradually occur : t-he entire surface 
contracts more and more, becomes smaller ; on the border, between skin 
and granulations, the secretion of pus diminishes ; first, a dry, red 
border, about half a line broad, forms and advances toward the centre 
of the wound, and, as it progresses and traverses the granular surface, 
it is followed closely by a bluish-white border, which passes into nor- 
mal epidermis. These two seams result from the development of 
epidermis, which advances from the periphery toward the centre ; 
cicatrization begins ; the young cicatricial border advances half a line 
or a line daily ; finally, it covers the entire granulation surface. The 
young cicatrix then looks quite red, and is thus sharply defined from 
the healthy skin ; it feels firm, more so than the cutis, and is still 
very intimately connected with the subjacent parts. In the course 
of some months, it gradually grows paler, softer, more movable, and 
finally white ; in the course of months and years, it grows still smaller, 
but often remains whiter than the cutis all through life. The 
strong contraction in the cicatrix often causes traction on the neigh- 
boring parts, an effect that is occasionally desirable, but sometimes 
very unwelcome, as, for instance, when such a cicatrix on the cheek 
draws the lower eyelid down, causing ectropion. 

You will occasionally see it asserted that the cicatrization of a 
granulating surface may sometimes begin from several patches of 
epidermis forming in its midst. This is only true of cases where por- 
tions of cutis with rete Malpighii have remained in the midst of the 
wound, as may readily happen in gangrenous wounds, as the caustic 
agent may penetrate unequally deep. Under such circumstances, epi- 
dermis again forms from some remaining portion of the papillary 
layer, that has the slightest possible covering of cells of the rete Mal- 
pighii ; at these points we have the same circumstances as when we 
have raised a vesicle on the skin by cantharides, inducing by the rapid 
exudation an elevation of the epidermis from the mucous layer of 
the skin ; this is followed by no granulations, if you do not continue 
to irritate the surface, but horny epidermis again forms at once over 
the mucous layer. But, if there be no such remnant of rete Malpighii, 
we never have these islands in the cicatrix, the formation of epidermis 
only takes place gradually, from the periphery of the wound toward 
the centre. I believe this so firmly, that I think surgeons, who say they 
have seen otherwise, must be mistaken in some way. 

The transplantation of epidermis after Reverdirts method also ap- 
pears to me to favor the view that epithelium is only developed from 
epithelium. 

After having considered the external conditions of the wound, the 
development of granulations, of pus, and of the cicatrix, we must 



DILATATION OF THE VESSELS. 



73 



now turn again to the more minute changes by which these external 
symptoms are induced. 

It will be simplest for us, again, to represent a relatively simple 
capillary net-work in the connective tissue : suppose a crescentic piece 
to be cut out of it from above ; first, there will be bleeding from the ves- 
sels, which will be arrested by the formation of clots as far as the 
next branches. Then, there must be dilatation of the vessels about 
the wound, which is due partly to fluxion, partly to increased press- 
ure; an increased transudation of blood serum, or an exudation, is 
also a necessary result of the capillary dilatation, from causes above 
given; the transuded serum contains some fibrogenous substance, 
which, by the influence of the newly-formed cells in the most super- 
ficial layers, coagulates to fibrine, while the serum, mixed with blood 
plasma, flows off. The vascular net-work would assume the following 
shape : - 

Fig. 4. 




Diagram of a wound, with loss of substance. Vascular dilatation, magnified 300-400 times. 



In most cases, from insufficient supply of blood-plasm at the sur- 
face of the wound, more or less particles of tissue will die ; as the 
stoppage of vessels must, of course, deeply affect the nutrition of tis- 
sues not very vascular, and, where the tissues are very stiff, dilatation 



74 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

of the vessels will be interfered with. Let us suppose that the upper 
layer, shaded in the diagram, is dead from the changes in the circula- 
tion. What will now take place in the tissue itself? Essentially, 
the same changes as in the united edges of a wound ; wandering 
of white-blood cells through the walls of the vessels, their collection 
in the tissue with the secondary action they induce ; plastic infiltra- 
tion, and inflammatory new formation. But, since there is no oppos- 
ing wounded surface, with which the new tissue can coalesce, then to 
be quickly transformed to connective tissue, the cells, escaping from 
the vessels, remain at first on the surface of the wound ; the exuded 
fibrinous material on the surface of the wound becomes soft and 
gelatinous ; at the same time, the infiltrated tissue of the surface of 
the wound assumes the same peculiarities ; the soft connective tissue, 
into which the young vessels shortly grow, even if only present in 
small quantities, holds together the cells of the inflammatory new for- 
mation, which constantly increase in number. The granulation tissue 
is thus formed ; this is, therefore, a highly-vascular inflammatory new 
formation. At first, it grows constantly, the direction of its growth 
is from the bottom of the wound toward the surface ; the tissue is, 
however, of different consistence in the various layers, its superficial 
surface especially is soft, and most superficially of fluid consistence, 
for here the intercellular substance becomes not only gelatinous, but 
fluid ; this uppermost thin fluid layer, which is constantly flowing 
and being constantly renewed from the granulation tissue by cell-exu- 
dation, is^s (Fig. 6). 

Hence, pus is fluid, as it were melted, dissolved inflammatory new 
formation. Where pus is present in quantity it must have come from 
some sort of granulation tissue or from some other highly-vascular 
and usually highly-cellular source ; this source need not always be a 
surface, as in the present case, but may lie deep in the tissue and form 
a cavity ; the centre of an inflammatory new formation anywhere in 
the tissue may break down into pus ; then we have an abscess. 

We shall frequently have occasion to speak of this relation of pus 
and granulations to each other ; hold fast to the idea of granulations 
being tissue (not granules), and of pus being fluid inflammatory new 
formation, and you will hereafter readily understand many processes, 
especially chronic inflammations, whose variable appearance you would 
otherwise find incomprehensible. 

Let us now say a few words about pus itself. If left standing in 
a vessel, it separates into an upper, thin, clear layer, and a lower yel- 
low one ; the former is fluid intercellular substance, the latter contains 
chiefly pus-corpuscles. On simple microscopic examination these are 
round, finely punctated globules, of the size of white-blood corpuscles ; 



GRANULATION TISSUE. 75 

they contain three or four dark nuclei, which become quite distinct 
on addition of acetic acid, because it dissolves the pale granules of 
the protoplasm, or at least swells them so that they become transpar- 
ent. The nuclei are not soluble in acetic acid ; the entire globule ia 
readily dissolved in alkalies. 



a, 



Fig. 5. 




Pus-cells from fresh pus, magnified 400 times, a, dead without addition ; b, the same cells after 
addition of acetic acid; c, various forms that living pus-cells assume in their amoeboid 
movements. 

At a and b we see the pus-cells as they usually appear when we 
cover a drop of pus with a thin glass, and without any addition ex- 
amine it under the microscope. The above-mentioned observations 
of Von Recklinghausen have shown that only the dead cells have this 
round shape ; if we observe the pus-cells in the moist chamber on a 
warmed object-table (according to M. Schultze), we see the amoeboid 
movement of these cells most beautifully. These movements, which 
only go on slowly and sluggishly at blood-heat, become more rapid 
at a higher temperature, and less so at a lower. The number of pus- 
cells in pus is so great, that in a drop of pure pus, under the micro- 
scope, the fluid intercellular substance is not at all perceived. Chemi- 
cal examination of pus is difficult, first, because the corpuscles can- 
not be completely separated from the fluid; also, because the large 
quantities of pus obtainable for chemical examination had already 
been a long time in the body, and may have changed morphologically 
and chemically ; and lastly, because chiefly protein substances are con- 
tained in pus, whose perfect separation hitherto has not always been 
possible. If we let pus from a wound stand in a glass, the clear, 
bright-yellow serum usually occupies more space than the thick, straw- 
yellow sediment, which contains the pus-corpuscles. Pus contains 
ten to sixteen parts of firm constituents, chiefly chloride of sodium ; 
the ashy constituents are about the same as those of blood-serum. 
Recent examinations of pus have shown that myosin, paraglobulin, 
protagon, fatty acids, leucin, and tyrosin, are constant constituents. 
Pus collected in the body does not readily undergo acid fermenta- 
tion ; pure fresh alkaline pus soon becomes sour, however, if it is 
left standing for a time even in a covered glass. 

Let us now return to the granulation layer, where we have still 
an important point to consider, namely, the numerous vessels, which 



76 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

give its red appearance. The extensive vascular loops that must 
form on the surface of the wound, and which in the diagram (Fig. 6) 
are too small and too few, commence, with the growth of the surround- 
ing granulation tissue, to elongate and become more tortuous ; tow- 
ard the .fourth or fifth day new vessels develop as fine lateral capil- 
lary communication, as in healing by first intention, and the tissue is 
soon traversed by an excessive number of vessels, which have so 
much effect on the appearance of the entire granulation surface that 
it is hardly recognizable on the cadaver, where the fulness of the ves- 
sels is wanting, or is at least less marked than during life, and the 
tissue consequently appears pale, relaxed, and much less thick. The 
question arises, Whence come these remarkable, small, gradually-con- 
fluent red nodules, which are visible to the naked eye ? Why does 
not the surface look even ? Indeed, this is frequently the case ; the 
granules are by no means always distinctly defined ; but it is not easy 
to explain the cause of their form. It is usually assumed that the 
granules are to be regarded as imitations of the cutaneous papillae; 
but, independent of the fact that it is incomprehensible why such 
structures should be imitated in muscle and bone, and that the gran- 
ules are usually ten times as large as the cutaneous papillae, this is 
no real explanation. The appearance of the granules, doubtless, de- 
pends on the arrangement of the vascular loops into tufts, on certain 
boundaries between the different groups of vessels. Hence we might 
suppose that the vascular loops acquire this form without known 
cause. Still, it seems to me natural to compare them to the circum- 
scribed capillary districts, already formed in the normal tissues, of 
which we have numerous examples, especially in the skin and in fat. 
You know that every sweat and sebaceous gland, every hair-follicle 
and fat-lobule, has its nearly-closed capillary net-work, and, by the 
enlargement of such capillary net-works, the peculiar closed vascular 
forms of the granules might arise. In fact, in the cutaneous and 
fatty tissue you will find the individual fleshy growths, particularly 
sharply and clearly defined, while this is more rarely the case in 
muscle, where these bounded capillary districts do not occur. It can 
only be decided by artificial injections of fresh granulations, whether 
this explanation is correct ; till then, it remains simply an attempt 
to refer this pathological new formation to normal anatomical con- 
ditions. 

The following sketch, in which, on account of the great enlarge- 
ment, and the small injured district, nothing can be seen of the granu- 
lar layer, may serve you as a diagram of the development of the gran- 
ulation tissue with its vessels, and of its relation to pus and to the 
subjacent matrix, as it has developed from Fig. 4. 



RESULTS OF GRANULATION. 



11 



If the growth of the granulations was not arrested at some point, 
a constantly-growing granulation tumor would be formed. Fortu- 
nately, this is never or very rarely the case. You already know, from 
the representation of the external conditions, that when the granula- 
tions have reached the level of the cutis, or even sooner, they cease 
to grow and are coated with epidermis, and retrograde to a cicatrix. 
The following changes occur in the tissue : At first, in the granula- 
tion tissue, as in the edges of the wound in healing by the first inten- 
tion, there are numerous cells which are destroyed. Not only the 
millions of pus-cells on the surface, but also cells in the depths of the 
granulation tissue, disappear by disintegration and reabsorption ; it is 
very probable that cells from the granulation tissue may pass back un- 
injured into the vessels, as we shall see when treating of the organi- 
zation of thromboses of the vessels. As the cells retrograde, fine fat- 
granules'gradually form in them, not only in the round but also in 
the spindle-shaped ones ; such cells, which are composed of very fine 

Pig. 6. 




Diagram of granulation of a wound ; the layer of pus-cells is represented as having been acted 
on by acetic acid, to distinguish the pus-cells in the figure more accurately from the granu- 
lation cells. Magnified 300-400 diameters. 



18 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



fat-globules, are generally called granular cells (Kdrnchenzellen) ; they 
often occur in the granulations, as above described. When the gran- 
ulation tissue is thus diminished by atrophy and escape of the cells, 
and at the same time the new formation of cells ceases, something im- 



FlG. 




Patty degeneration of cells from granulations. Granulation-cells. Magnified about 500 diameters. 

portant must happen, that is, the gradual consolidation of the gelat- 
inous intercellular tissue to striated connective tissue, which is 
brought about by the steadily increasing loss of water, that is carried 
off by the vessels and evaporated from the surface ; then the remain- 
ing cells at once assume the shape of the ordinary connective-tissue 

Fig. 7 a. 




a, Epithelial cells from frog's cornea, throwing out shoots at the edge of a loss of substance, b, Some 
cells detached from such a border. Magnified about 660. Heiberg. 

corpuscles. According to the view of other observers, the original 
intercellular substance entirely disappears, and its place is supplied by 
the protoplasm of granulation cells, which transforms into fibrous tis- 
sue. With these changes which take place from the periphery tow- 
ard the centre, the secretion of pus on the surface ceases ; at the very 



RESULTS OF GRANULATION. 79 

circumference of the wound on the condensing granulation tissue 
epidermis forms and quickly separates into hard epidermic and mucous 
layers ; according to J, Arnold, this formation takes place by the di- 
vision of a protoplasm, at first entirely amorphous, in the immediate 
vicinity of the existing border of epidermis. Lastly, the superfluous 
capillaries must be obliterated; few of them remain to keep up the 
circulation through the cicatrix. With their obliteration the tissue be- 
comes drier, tougher, contracts more and more, and often the cicatrix 
does not acquire its permanent form and consistence for years. 

The whole process, like all these modes of healing, contains much 
that is very remarkable, although recent investigations have explained 
many of the more minute morphological changes. The possibility, 
nay, the necessity, under otherwise normal circumstances, of arriving 
at a typical termination, is the chief characteristic of those new forma- 
tions that are induced by an inflammatory process. If this natural 
course of healing does not take place, it is because either constitu- 
tional or local conditions indirectly or directly interfere, or because the 
organ attacked is so important to life, the disturbance to the entire 
body so severe, that there is death of the organ, or of the individual, 
or that the functional disturbance of the former causes the death of 
the latter. Every new formation, due to inflammation, always has the 
tendency to reach a certain point, to retrograde, and pass into a sta- 
tionary state, while other new formations have no such natural termi- 
nation, but usually continue to grow. 

Different as healing by the first and second intentions appears, at 
the first glance, the morphological changes in the tissue are in both 
cases the same ; you only need to divide Fig. 3 at a, to have the same 
picture as in Fig, 6. Observation teaches in the simplest manner that 
this is actually so ; if a wound almost healed by first intention, but 
not yet consolidated, be torn open, we have a granulating wound 
which soon suppurates. You will hereafter be frequently convinced 
of this in practice. 

The above process of healing by immediate adhesion and by gran- 
ulation we have termed traumatic inflammation, and have found it 
identical with some other forms of inflammation ; it has also been 
stated that a marked peculiarity of traumatic inflammation is, that in 
it, without some further cause, the irritation in the tissue does not 
extend beyond the immediate vicinity of the injury. I beg you 
carefully to remember this limitation. As we know nothing ac- 
curately about the chemical changes and nerve-actions in the in- 
flamed tissue, while we do know the morphological processes very 
accurately, we naturally attend most to the latter if we wish to de- 
fine and generalize the term " inflammation." I will briefly take up 



80 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

the previous views on this subject (p. 48). " Inflammation " is a 
modification of the normal physiological processes in the different 
tissues of the body, a " disturbance of nutrition " ( Virchow) whose 
histopoetic results you now know and of whose destructive, deleteri- 
ous actions you will hereafter hear. Any part of the body was said 
to be " inflamed " when it was hot and red ; as it is then generally 
swollen and painful also, this name is applied to processes where the 
above symptoms occur. The word inflammation originated when 
there were no true pathologico-anatomical ideas ; even the oldest ob- 
servers understood that something unusual was going on in the 
tissues, that they were much heated {inflammatio) , and from the first 
this process has been regarded as an intense increase of the vital 
processes. As they could not understand the process itself any bet- 
ter than we do, they considered the symptoms and the results of the 
process, just as we do ; so that doubts often arose if it were proper 
to speak of inflammation when one or other symptom was absent or 
not well marked, just as it is to-day. We now know that inflammation 
is not an existence outside of the body, which makes its way into 
some part and there grows, and must be expelled like Beelzebub, 
and we know why " tumor, rubor, calor, dolor," are caused by in- 
flammation, but although any one usually recognizes an acute inflam- 
mation as such and designates it correctly, it still remains difficult as 
well clinically as anatomico-pathologically to give an exact definition 
of " inflammation." There is no difficulty in distinguishing an oak 
from an ass ; but, if you attempt to generalize and give a sharp defi- 
nition between plants and animals, you will have the greater difficulty 
the more you know of the details of botany and zoology. The word 
"inflammation" is in use, and so accurately designates those pro- 
cesses to which it was first applied, that it would be useless to try to 
root it out. By it we understand the above-described combination 
of processes in the tissues, which in the present case arise from a 
purely mechanical irritation (wound) acting only once. How much 
hyperemia, exudation, and new formation of tissue is required before 
we can term the process inflammation cannot be stated absolutely. 
It seems to be agreed by surgeons and anatomists to designate as 
" inflammatory " the purely regenerative processes, that is, the neo- 
plastic tissues, which directly or indirectly replace the loss of sub- 
stance. If we consider the process in the modern histological sense, 
it cannot be accurately defined from the inflammatory, slight as it may 
be occasionally. From a purely clinical point of view, the distinction 
is easier, as we often meet cases without any of the four cardinal 
symptoms on the edges of the wound ; and still the difference be- 
tween a slight redness, swelling, and sensitiveness of the borders of 



PREPARATIONS SHOWING HEALING OF WOUNDS. 81 

the wound to an intense, progressing inflammation over the entire 
affected portion of the body is only one of degree. Custom has here 
made a distinction ; when a wound heals without any symptoms of 
so-called reaction we do not call it inflammation of the wound, but 
only apply this term when the symptoms of inflammation are very 
prominent at the part injured. 

I deemed it necessary to speak to you of these general consider- 
ations on inflammation, so that you might early learn some of the 
difficulties of the subject. In these lectures it will always be my ob- 
ject to explain to you, as clearly as is now possible, the anatomico- 
pbysiological disturbances, and at the same time to show you histo- 
logically the origin of the clinical descriptions and expressions now 
in use. This is the only way we can truly ground our knowledge ; 
without understanding this you would always be feeling around the 
outside of symptoms, and by clinging to certain ones fall into in- 
curable dogmatism, which in a country doctor the world calls " nar- 
row-mindedness," in the eminent city physician " infallibility." As 
the great majority of men are stupid in physical matters, you are 
sure even with the latter peculiarities of attaining great practical 
success, but you must then renounce all idea of appreciating or ad- 
vancing the progress and development of society. 

It is not the object of these lectures to show you on preparations, step 
by step, the morphological microscopical changes in wounded tissue — 
you will see these, in the practical lessons on pathological histology — 
but I will show you a few points, so that you may not think that the pro- 
cesses of which I have spoken can only be demonstrated on diagrams. 

The cell-infiltration of tissue, after irritation by an incision, is best 
seen in the cornea. Four days ago I made an incision, with a lance- 
shaped knife, in the cornea of a rabbit ; yesterday the incision was 
visible as a fine line with milky cloudiness. I killed the animal care- 
fully, cut out the cornea, and let it swell in pyroligneous acid, till this 
morning ; then made a section through the wound, and cleared ifc up 
with glycerine. 

Now, at a a (Fig. 8), you may see the connecting substances be- 
tween the edges of the wound, in which there has been a considerable 
collection of cells, between the lamellae of the cornea, where the cor- 
neal corpuscles lie. These cells are not so evident in the method em- 
ployed as in that where carmine is used, still the intermediate sub- 
stance between the edges of the wound is very distinct. As you see, 
it consists almost entirely of cells ; the cells alone would not, however, 
render the union sufficiently firm, if they were not glued together by 
a fibrinous cement. The young cells probably come out of the edges 
of the wound from the fissures between the corneal lamellas, and prob- 
ably do not originate in the connective substance between the edges 
6 



82 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



of the wound ; on the contrary, the latter is finally formed from them. 
Let me remark incidentally, these fine corneal cicatrices subsequent- 
ly clear up, so as to leave scarcely a trace. All the cells that you 
here see in the preparation come from the vascular loops of the con- 
junctiva ; the normal stellate corneal cells are not visible here. I have 
chosen this specimen because the intermediate substance is broad and 
very rich in cells. In very small incisions, made in the cornea with a 
very sharp knife, the intermediate substance is so slight, that it is seen 
with difficulty ; then, too, the changes on the edges of the wound are 
slighter than here, and so slight a scar is not visible to the naked eye. 
Here (Fig. 9) you have a transverse section through a twenty-four- 

Fig. 8. 




Corneal incision three days old ; a a, the uniting substance between the two 
ion. Magnified 300 diameters. 



of the incis- 



liour old, freshly-united wound in the cheek of a dog. The incision is 
well marked zX a a ; the edges of the wound are separated by a dark, 
intermediate substance, which consists partly of white cells, partly of 
red corpuscles — the latter belong to the blood, escaped between the 
edges of the wound, after the injury ; the connective-tissue fissures 
crossed by the wound, in which the connective-tissue cells lie, are 
already filled with numerous newly-formed cells, and these cells have 
already pushed into the extra vasated blood between the edges of the 
wound. The preparation has been treated w T ith acetic acid, hence you 
no longer see the striation of the connective tissue, but see the young 
cells more distinctly. Look particularly at certain strings, rich in 
cells, that extend from the wound toward both sides (b b b) ; these 
are blood-vessels in whose sheaths many cells are infiltrated ; this is 
apparently because here many w T hite-blood cells have passed through 



PREPARATIONS SHOWING HEALING OF WOUNDS. 



83 











Incised wound twenty-four hours old, in the cheek of a dog. Magnified 300 diameters. 



the walls of the blood-vessels, or are about to do so. About the 
transformation of the coagulated blood between the edges of the 
wound, the wound thrombus, we shall hereafter speak more fully 
when treating of cicatrices of the vessels at the end of this chapter. 

This preparation (Fig. 10) shows a young cicatrix, nine days after 
the injury. 

Fie. 10, 




Cicatrix nine days after an incision through the lip of a rabbit, healed by first intention. Magni 

fied 300 diameters. 

The connective substance (a a) between the edges of the wound 
consists entirely of spindle-cells pressed together, which are most inti- 
mately connected with the tissue on both sides of the wound. 



84 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



Fine sections cannot be made of granulation tissue, just taken 
from a wound ; it is generally a very difficult subject for fine prepara- 
tions. If you harden the granulation tissue in alcohol, color the sec- 
t ion with carmine, then clear it up with glycerine, you have a speci- 
men like Fig. 11. 

Fig. 11. 




Granulation tissue. Magnified 300 diameters. 

The tissue appears to consist solely of cells and vessels, with very 
thin walls ; the whole tissue is shrunken by the alcohol, so that we 
here see nothing of the mucous intercellular substance which is al- 
ways present, even if only in small quantities, in healthy, fresh granu- 
lations. 

We see the tissue of the young cicatrix particularly well in the 
following preparation (Fig. 12), which was taken from a broad cica* 
trix, following granulation and suppuration, in the back of a dog, 
about four or five weeks after the injury. 



Fie. 12. 




Young cicatricial tissue. Magnified 300 diameter*. 



PREPARATIONS SHOWING HEALING OF WOUNDS. 



85 



The preparation has been treated with acetic acid, to show the ar- 
rangement of the connective-tissue cells, that have formed from the 
granulation tissue ; a a a are partly obliterated, partly still permeable 
blood-vessels ; the connective-tissue cells are still relatively large, suc- 
culent, and distinctly spindle-shaped, still the intercellular substance is 
richly developed. 

To study the state of the blood-vessels in the wound, we must 
make injections ; this is quite difficult, and quick success often depends 
on a lucky chance. 

Fig. 13. 




Horizontal section through the tongue of a dog-, near the surface, marie with a hroad knife. 
Frontal section through the tongue after injection and hardening, forty-eight hours after the 
injury. Magnified 70-80 diameters ; after Wywodzqf—a a, intermediate substance between 
the edges of the wound (consisting of filamentary-looking adhesive material and estrava- 
sated blood). The section has passed through two layers of muscle crossing each other. 
Looping of the vessels with dilatation in both borders of the wound ; commencing elonga- 
tion of the loops into the connective suhstance. 



On this subject we have the recent works of Wywodzoff and 
Thiersch, whose results in the main agree partly with one another, 
partly with my investigations on this subject. Wywodzoff, who op- 
orated on dogs' tongues, gives a series of representations of the con- 



86 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



dition of the blood-vessels in various stages of healing of the wound, 
a few of which I shall demonstrate to you, without, however, going 
into the more minute details of the formation of vessels. 



Fig. I 




Similar section of a dog's tongue as in Fig. 13. — Cicatrix (a) ten days old: everywhere anas- 
to -noses of the vessels from the two edges of the wound. Magnified 70-80 diameter; 
niter Wyuxctnff. 



Fig. 15. 




Similar section of a doe's tonsrae as in Fisr. 13.— Cicatrix (a) sixteen davs old. The vessels 
already greatly diminished and ai rophied. Magnified 'TVS ) diameters : alter Wywodzoff. 



PREPARATIONS SHOWING HEALING OF WOUNDS. 



87 



This (Fig. 16) is a preparation of granulations from a human be- 
ing, where the vessels were tolerably filled by natural injection ; tLe 
vascular loops are very close together and complicated at the surface; 
leep down the vessels run nearly parallel. 



Fia. 16. 




Granulation vessels. Magnified 40 diameters. 

In conclusion, here is a preparation of injection of the lymphatic 
vessels of a dog's lip. You see that the young cicatrix, on the seventh 
day, when it still consists almost exclusively of cells, has no lymphatin 



Fig. 17. 




Seven-days-old wound in the lip of a dog. Healing by the first intention. Injection of the 
lymphatic vessels : a, mucous membrane ; b, young cicatrix. Magnified 20 diameters. 



vessels ; these cease immediately at the young cicatrix ; they do not 
form in the cicatrix till the fibrillar connective-tissue bundles form. 
The granulation tissue also has no lymphatic vessels; where the in- 



88 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

flammatory new formation, where the primary cellular tissue forms, the 
lymph-vessels are mostly closed, partly by fibrous coagulations, partly 
by new cell formations. These observations have also been confirmed 
quite recently by Zosc7i, of St. Petersburg, by examinations of trau- 
matically inflamed testicles. 



LECTURE VIII. 

General Eeaction after Injury. — Surgical Fever. — Theories of the Fever. — Prognosis.— 
Treatment of Simple Wounds and of Wounded Persons. — Open Treatment of 
Wounds. 

Gentlemen : You now know the external and internal minute 
processes in the healing of wounds, so far as it is possible to follow 
them with our present microscopes. 

Of the wounded person we have not yet spoken. If you have crit- 
ically examined his condition, you will have noticed changes, which 
may not be explained by cell-knowledge (mit Zellenweisheit), and 
perhaps not at all. ■ 

Possibly even the first day the patient may have been restless 
toward evening ; he may have felt hot, thirsty, with no appetite, some 
headache, wakeful at night, and dull the next morning. These sub- 
jective symptoms increase till the evening after the next day. If we 
feel the pulse, we find it more frequent than normal, the radial artery 
is tenser and fuller than before ; the skin is hot and dry ; we find the 
bodily tempertaure elevated ; the tongue is coated and readily becomes 
dry. You already know what ails the patient — he has fever. Yes, he 
has fever ; but what is fever ? whence comes it ? what connection is 
therebetween the different remarkable subjective and objective symp- 
toms ? But do not ask any more questions, for I can scarcely answer 
those already proposed. 

By the name " fever " we designate the combination of symptoms 
which, in a thousand different shapes, almost always accompanies in- 
flammatory diseases, and is generally apparently due to them. We 
know its duration and course in various diseases ; still, its nature is not 
fully understood, although it is better known than formerly. 

The different fever symptoms appear with very variable intensity. 
Two of these symptoms are the most constant, viz., the increase of 
pulse and bodily temperature ; we can measure both of them, the first 
by counting, the latter by the thermometer. The frequency of the 
heart's beat depends on many things, especially on psychical excite- 
ment of all sorts ; it shows slight differences in sitting, lying, standing, 



SURGICAL FEVER. 89 

walking. Hence, there are many things to which we must attend, if we 
would avoid error. However, w^e may avoid these mistakes, and for 
centuries the frequency of the pulse has been used as a measure of 
fever. Examination of the pulse also shows other things important to 
be known : the amount of the blood, tension of the arteries, irregu- 
larity of the heart-beat, etc. ; and it should not be neglected even now 
that we have other modes of measurement of the fever. This other, 
and in some respects certainly better, mode of measuring the amount 
and duration of the fever is determination of the bodily temperature 
with carefully-prepared thermometers, whose scales are divided, accord- 
ing to Celsius, in one hundred degrees, and each degree in ten parts. 
The introduction of this mode of measurement into practice is due to 
Von Btirensprung, Traube, and Wunderlich ; it has the advantage of 
graphically presenting the measurements, which are usually made at 
9 A. m. and 5 p. m., as curves, and making them at once easily read. 

A series of observations of fever in the normal course of wounds 
shows the following points: traumatic fever occasionally begins imme- 
diately after an injury, more frequently not till the second, third, or 
fourth day. The highest temperature attained, although rarely, is 
104.5° F.-105.5 ; as a rule it does not rise much above 102°-103°. 
Simple traumatic fever does not usually last over a week ; in most 
cases it only continues from two to five days ; in many cases it is en- 
tirely absent, as in most of the small superficial incised wounds of 
which we spoke above. Traumatic fever depends entirely on the state 
of the wound ; it is generally of a remitting type ; the decline may 
take place rapidly or slowly. 

From these observations we should naturally suppose the fever 
would be the higher the more severe the injury. If the injury be too 
insignificant, there is either no fever or the increase of temperature is so 
slight and evanescent as to escape our modes of measurement. It has 
been thought that a scale of injuries might be constructed, according to 
which the fever would last a longer or shorter time, and be more or 
less intense, in proportion to the length and breadth of the wound. 

This conclusion is only approximately correct, after making very 
considerable limitations. Some persons become feverish after very 
slight injuries ; others do not, even after severe ones. The cause of this 
difference in the occurrence of traumatic fever depends partly on 
whether the wound heals with more or less inflammatory symptoms, 
partly on unknown influences. We cannot avoid the supposition that 
purely individual circumstances have some influence : we see that, from 
similar injuries, one person will be more disposed to fever than an- 
other. 

Before going on to examine how the state of the wound is related 



90 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

Co the general condition, we must examine the latter a little more 
carefully. The most prominent and physiologically the most remark- 
able symptom of the fever is the elevation of the temperature of the 
blood, and the consequent increase of the bodily temperature. All 
the modern theories of fever turn on the explanation of this symptom. 
There is no ground for supposing that in fever any absolutely new 
element must be added to the requirements acting for the preservation 
of a constant temperature in the body, but it is probable that the fever 
temperature is caused by some change of the normal requirements of 
temperature, which vary readily with circumstances. When you re- 
member that men and animals in the varied temperatures of summer 
and winter, in hot and cold climates, have about the same temperature 
of the blood, you will see that the conditions of production and giving 
off of heat are susceptible of great modification, and that within these 
conditions there may very possibly be abnormities of the resulting 
bodily temperature. It is evident a priori that an increase of bodily 
temperature may depend either on diminution of the amount of heat 
given off, the production remaining the same, or on increased produc- 
tion, the loss of heat remaining the same (other relations of these 
factors to each other are possible, but I shall pass over them, to avoid 
confusing you on this difficult question). The decision of this cardinal 
question does not seem possible at present ; it would be possible by 
determining and comparing the quantity of heat produced in fever 
and in normal conditions, by the so-called calorimetrical experiments 
on men and large warm-blooded animals ; but hitherto there have been 
great difficulties in the way of these experiments. Liebermeister and 
Ley den have invented methods of calorimetry, that seem to me cor- 
rect; but the methods and conclusions of Liebermeister have been 
energetically combated by Senator. Hence, in regard to the above 
questions, we are still, to a great extent, thrown on probability and 
hypothesis. As the production of heat depends chiefly on oxidation 
of the constituents of the body, increase of the latter would necessarily 
be followed by increase of the former if the loss of heat remained the 
same. Now, since the amount of urea is regarded chiefly as the result 
of the burning up of the nitrogenous bodies, and as the amount of urea 
excreted in fever is usually increased, and the weight of the body 
rapidly decreases, as appears from the experiments of 0. Weber, Lieber- 
meister, Schneider, and Ley den, this, with the above-mentioned calori- 
metric experiments, is considered strong proof that in fever the con- 
sumption is greatly increased, and that consequently more warmth is 
really produced than in the normal state, more than can be disposed 
of by the body in the same time. Traube gives another view of the 
occurrence of fever-heat : he asserts that every fever begins with ener- 



ELEVATION OF TEMPER ATUKE IN INFLAMMATION. 91 

getic contraction of the cutaneous vessels, especially of the smallei 
arteries, and that thus the giving off of heat to the air is decreased, and 
more heat collected in the body, without its actually producing more. 
Although this hypothesis is advanced by its author with wonderful 
ability and acuteness, and is apparently supported by the work of 
Senator, I, with most pathologists, cannot agree with it, especially as 
the premises, the contraction of the cutaneous vessels, can only be ac- 
knowledged in the cases begining with chill ; but this chill is by no 
means a constant symptom in the fever. Hence, in what follows, we 
shall start from the point that in fever there is increased production 
of heat. Then arises the question, How does inflammation generally, 
and traumatic inflammation particularly, effect the increase of bodily 
temperature ? This question is answered in various ways : 

1. At the point of inflammation, as a result of the lively interchange 
of tissue, heat is produced ; the blood flowing through the inflamed 
part is warmed more, and distributes the abnormal amount of heat here 
acquired, to the whole body. That the inflamed part is warmer than 
the non-inflamed is readily proved, especially in superficial parts, as in 
the skin, but this does not prove that more warmth is produced here 
than is usual, but is probably simply due to the circulation of more blood 
through the dilated capillaries ; if the inflamed part be not warmer than 
the blood flowing to it, it is not probable that it should produce heat. 
The investigations on this point are numerous and contradictory. The 
thermometrical measurements of 0. Weber and Hvfschmidt have given 
various results ; usually the temperature in the wound and in the rec- 
tum (which has about the warmth of arterial blood) were equal; occa- 
sionally the former was higher than the latter, sometimes the reverse ; 
the difference was never great, not being more than a few tenths of a 
degree in any case. Recently 0. Weber has hit on a new method of 
measurement, the thermoelectric : by his very difficult investigations 
the question seemed to be decided that the inflamed part is always 
warmer than the arterial blood ; indeed, that the venous blood coming 
from the seat of inflammation is warmer than the arterial blood going to 
it. Quite recently these investigations were repeated in Konigsberg 
by H. Jacobson, M. Bernhardt, and G. Zaudien, with the final re- 
sult of showing no increase of warmth in the inflamed part. From the 
contradiction of the results of observation it is impossible to form a 
judgment on this point. Nevertheless it seems certain that in the in- 
flamed part there is not enough heat produced to elevate the tempera- 
ture of all the blood in the body several degrees. 

2. The irritation induced by the inflammation on the nerves of the 
inflamed part might be supposed as advancing to the centres of the 
vasomotor (nutrient) nerves ; the excitement of the centres of these 



92 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

nerves would induce increase of the general change of tissue and con- 
sequent increase of the production of warmth. This hypothesis, which 
is supported by some facts, such as the great difference in febrile irri- 
tability, and which I formerly maintained, no longer appears to me 
tenable ; it is opposed by the experimental researches of Breuer and 
Chrobak, which prove that fever occurred even when all the nerves 
were divided, by which there could be any conduction from the periph- 
eral injury to the nerve-centres ; the recent investigations oi Ley den also 
oppose this hypothesis, since they prove that there is no constant re- 
lation between the loss of nitrogenous material, or consumption, and 
development of warmth. 

3. Since, from the nature of the process, in the inflamed part some 
of the tissue is destro}- ed, while some new tissue is formed, it is not 
improbable that some of the products of this destruction enter the 
blood, partly through the blood-vessels, partly through the lymph- 
vessels ; such material acts as a ferment, excites change in the blood, 
as a consequence of which the entire amount of blood may be Avarmed. 
We might also admit a more complicated mode of development of 
warmth, which, by including the nervous system, might in some re- 
spects be more serviceable theoretically ; the blood changed by taking 
up the product of irritation might prove irritant to the centres of the 
vaso-motor nerves, and thus induce increased production of warmth. 
The decision between these different hypotheses is difficult ; they are 
all about equally justifiable, and all have the common factor of pollu- 
tion of the blood by material from the seat of inflammation or the 
wound, which is recognized as having an effect on the production 
of heat ; these substances must have the effect of exciting fever 
(a pyrogenous action). This was to be proved. It has been proved 
by experiments of 0. Weber and myself, which I can notice only 
briefly here. In most open wounds, especially in contused wounds, 
shreds of tissue are always decomposed ; in many idiopathic inflam- 
mations, the circulation is arrested at different points in the inflamed 
tissue, and there is partial decomposition of these dead portions. 
Decomposing tissue, then, was an object to be examined in regard 
to its pyrogenous action. If you inject filtered infusions of this 
substance into the blood of animals, they have high fever, and not 
unfrequently die with symptoms of debility, of somnolence, with coin- 
cident bloody diarrhoea. The same effect is induced by fresh pus in- 
jected into the blood ; a weaker effect follows the employment of juice 
and pus serum pressed out of the inflamed part, but the secretion 
from the wound taken during the first forty-eight hours is especially 
active. Hence the products of decomposition, as well as those of 
new formation, have a pyrogenous action in the blood. These prod- 
ucts are of a very complicated and variable nature ; some of the 



PYROGENOUS MATERIALS. 93 

chemical substances in them have been independently tested in re- 
gard to their fever-exciting qualities : we may induce fever by inject- 
ing leucin, sulphuretted hydrogen, sulphides of ammonium and car- 
bon, and other chemical substances resulting from the decomposition 
of tissue, or even b} 7 " injecting water ; decomposing vegetable matter 
also has a fever-exciting effect. Hence there are no specific fever- 
exciting substances, but the number of pyrogenous materials is in- 
numerable. 

I may here mention that the bad-smelling substances developed 
by the decomposition of the tissues are probably the least dangerous. 
I intentionally distinguish the products of decomposition in acute 
inflammations, which are usually odorless at first (whose activity as 
poisons we first learned by experiment), from those of decomposing 
dead bodies, which generally smell bad at once, although their pyro- 
genous action is similar. If a wounded patient has fever, it is for 
me a proof that there is decomposition going on in his wound, and 
that the products have passed into the blood, whether the wound 
smells or not. 

After the pyrogenous effect of the products of inflammation and 
decomposition had been absolutely confirmed, it remained to be proved 
that this material could be taken from the tissue into the blood, and 
to be shown how this took place. For this purpose it was injected 
into the subcutaneous cellular tissue, where it spread around in the 
meshes of the tissue ; the effect, as to fever, was the same as when the 
injection was made directly into the blood ; hence the pyrogenous 
material is absorbed from the cellular tissue. Here there is another 
observation to be made : after a time, at the point where decomposing' 
fluid or fresh pus has been injected, there is severe and not unfrequently 
rapidly progressive inflammation. For instance, I injected half an 
ounce of decomposing fluid into the thigh of a horse ; in twenty-four 
hours the whole leg was swollen, hot, and painful, and the animal very 
feverish. I did the same thing with the same result, with fresh (not 
decomposing) abscess pus, in a dog. This action of pus and putrefy- 
ing matter in exciting local inflammation I call phlogogenous. All 
pyrogenous substances are not at the same time phlogogenous ; some 
are more so than others, and, especially in the putrefying fluids, it 
makes a great deal of difference whether the poisonous power, which 
we do not know accurately, is present in greater or less quantities. 

It is not certainly determined whether the pyrogenous materials 
enter the blood through the lymph or blood-vessels; they may vary in 
this respect. Some points are in favor of the reabsorption taking 
place chiefly through the lymphatics. 5 

There is still something to be said about the course of the fever 



94 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

artificially induced in animals. The fever begins very soon, often 
even in an hour after the injection ; after two hours there is always 
considerable elevation of temperature : for instance, in a dog whose 
temperature in the rectum was 103° F., two hours after an injection of 
pus it may be 105°, and four hours after the injection lO? . It is im- 
material whether the substance be injected directly into the blood or 
into the cellular tissue. The fever may remain at its height from one 
to twelve hours, or even longer. The defervescence may be either 
gradually or by crisis. If we make new injections, the fever increases 
again ; by repeated injections of putrefying material we may kill the 
largest animal in a few days. Whether an animal shall die from a 
single experiment, depends on the amount and poisonous qualities of 
the injected material in relation to the size of the animal. A medium- 
sized dog, after the injection of a scruple of filtered decomposing fluid, 
may be feverish for a few hours and be perfectly well after twelve 
hours. Hence the poison may be eliminated by the change of tissue, 
and the disturbances induced by its presence in the blood may again 
subside. 

I will now terminate these observations, and only hope I may have 
made this important subject, to which we shall frequently return, 
comprehensible to you. I feel convinced that traumatic fever, like 
any inflammatory fever, essentially depends on a poisoned state of 
the blood, and may be induced by various materials passing from the 
seat of inflammation into the blood. In the accidental traumatic 
diseases we shall again take up this question. 

Now a few words about the prognosis and treatment of suppurat- 
ing wounds. 

The prognosis o£ simple incised wounds of the soft parts depends 
chiefly on the physiological importance of the wounded part, both as 
regards its importance in the body and as regards the disturbance of 
function in the part itself. You will readily understand that injuries 
of the medulla oblongata, of the heart, and of large arterial trunks 
lying deep in the cavities of the body, should be absolutely fatal. 
Injuries of the brain heal rarely; the same is true of injuries of the 
spinal medulla — they almost always induce extensive paralysis and 
prove fatal by various secondary diseases. Injuries of large nervous 
trunks result in paralysis of the part of the body lying below the seat 
of injury. Openings into the cavities of the body are always very 
serious wounds; should they be accompanied by injury of the lung, 
intestines, liver, spleen, kidney, or bladder, the danger increases ; 
many of these injuries are absolutely fatal. Opening of the large 
joints is also an injury which not only often impairs the function of 



TREATMENT OF SIMPLE INCISED WOUNDS. 95 

the joint, but is often dangerous to life from its secondary effects. 
External circumstances, the constitution and temperament of the pa- 
tient, have also a certain influence on the course of cure. Another 
source of danger is the accessory diseases which subsequently arise, 
and of which unfortunately there are many ; of these we shall here- 
after speak in a separate chapter. You must for the time being con- 
tent yourselves with these indications, whose further elucidation 
forms a very considerable part of clinical surgery. 

We may give the treatment of simple incised wounds very briefly. 

We have already spoken of the uniting of wounds without loss of 
substance, and the proper time for removing the sutures, and that is 
about all that we can regard as directly affecting the process of heal- 
ing. Still, as in all rational therapeutics, here it is most important : 
1. To prevent injurious influences that may interfere with the nor- 
mal course ; 2. Carefully to watch the occurrence of deviations from 
the normal, and to combat them at the right time, if possible. 

If we, first of all, limit ourselves to local treatment, we have no 
remedy for decidedly shortening the process of healing by first inten- 
tion or by suppuration, say to half its time'or less. Nevertheless, 
most wounds require certain care, although innumerable slight wounds 
heal without being seen by a surgeon. The first requirement for 
normal healing is absolute rest of the injured part, especially if the 
wound has extended through the skin into the muscles. Hence, in 
wounds at all deep, it is very necessary that the patient should not 
only keep his chamber, but that he should remain in bed for a time, 
as it is evident that the movement of injured parts, especially of in- 
jured muscles, must interfere with the process of healing. The sec- 
ond important point is cleanliness of the wound and its vicinity. 
Formerly it was always considered necessary to cover the wound, and 
to apply dressings in all cases. Of late I have grown doubtful if this 
be indeed necessary ; indeed, I would go so far as to assert that in 
many cases it is well not to apply any dressings. In wounds that 
have been sewed up, it has often been observed that it does no harm 
to leave them uncovered. If we wish to cover sutured wounds, on 
account of pain, redness, and swelling, or because they are in a part 
of the body upon which the patient must lie, we may apply various 
kinds of dressing ; we may smear the edges of the wound with pure, 
fine oil, best with almond-oil, and lay on a fold of linen dipped in oil, 
which should be changed daily, till the sutures are removed ; or else 
we may apply a linen compress three or four layers thick, and the 
size of the wound, wet with water, and cover it with oil-silk, gutta- 
percha sheeting, or parchment-paper, and make a few loose turns of 
a bandage over it. 



96 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

For some time past I have used as the immediate covering of 
recent wounds merely a moistened thin sheet of gutta-percha, over 
this a moist compress ; and to prevent the latter from drying, I 
cover it with some waterproof stuff, such as glazed paper, gutta- 
percha, or oiled silk, and then cover with plenty of dry wadding (de- 
prived of fat and made bibulous by cooking in lye). This dressing 
may be removed without wetting or giving pain ; it is to be retained 
in place by a bandage or adhesive plaster. For moistening the 
compresses and the sheet of gutta-percha, which lies directly on the 
wound, we generally employ liquids which arrest the decomposition 
of the secretion from the wound and prevent its smelling badly, that 
is, which are antiseptics and deodorants, and at the same time may 
destroy any infectious matters clinging to the dressings. In my 
clinic, for this purpose we employ saturated solution of chloride of 
lime, aqua plumbi, solutions of carbolic acid, carbolate of soda, and 
sulphate of soda (10 per cent.). I have not noticed any decided 
difference in their effect, and on the score of economy use solution 
of chloride of lime for ordinary dressings. 

The frequency with which the dressings of a simple wound should 
be renewed depends on the amount of secretion. As a general rule, 
during the first four days the dressing above described should be 
removed at least twice daily ; if during the first and second days 
the secretion escapes in a few hours, the dressing should be changed 
at once. In doing this we no longer need to use a syringe, and to 
carefully work off the charpie from the wound, while the patient 
suffers tortures ; should it ever be necessary to inject fistulous 
wounds, of which we shall hereafter speak, we may use either a sim- 
ple syringe or an HJsmarcNs douche, which consists of a cylindrical 
vessel 25 centimetres high and 12 in diameter, with a short tube in- 
serted at its bottom, on to which a rubber tube with a nozzle is 
applied ; when this vessel is held up by an attendant, it acts as a 
syringe. It is generally enough to wipe off the wound with a little 
wadding when changing the dressing, and it is not necessary to 
remove every trace of pus. 

In many cases this dressing may be continued for weeks, being 
after a time applied only once daily, and then every two or three 
days ; cicatrization goes on and the wound heals without doing any 
thing more. 

Nevertheless, independent of certain diseases of the granulations, 
of which we shall speak more particularly hereafter, it frequently 
happens that under a continuance of the same treatment the heal- 
ing is arrested ; for days the process of cicatrization does not ad- 
vance, and the granulating surface assumes a flabby appearance. 



TREATMENT OF SIMPLE INCISED WOUNDS. 97 

Under such circumstances it is advisable to change the dressing, to 
irritate the granulating surface by new remedies. These temporary 
arrests of improvement occur in almost every large wound. Under 
such circumstances you may order fomentations of warm camomile- 
tea ; several compresses may be dipped in the warm tea, wrung out, 
and from time to time applied fresh to the wound ; or you may pre- 
scribe lotions of lead-water. You may also paint the wound from time 
to time with a solution of nitrate of silver (two to five grains to the 
ounce of water). If the wound-surface be no longer large, you may 
finally make use of salves ; these should be spread thinly over charpie 
or linen ; the most suitable are the basilicon-ointment (compound 
resin cerate, consisting of oil, wax, resin, suet, and turpentine) and 
a salve of nitrate of silver (one grain to a drachm of any salve, with 
the addition of Peruvian balsam). If the cicatrization be already far 
advanced, we may employ zinc-salve (zinc, oxide 3 j, ung. aq. rosse 
I j), or let the dry charpie adhere, and have the last portion of the 
wound heal under the scab. 

A very peculiar and occasionally a very efficient method of hast- 
ening cicatrization of granulating wounds lias been introduced by 
Meverdin. He found that a small portion of cutis taken from the 
surface of the body with concave scissors, and fastened with the raw 
surface on the granulations by means of adhesive plasters, not only 
becomes adherent, but the transplanted epidermis begins to grow 
and forms the centre of a so-called cicatricial island, whence the skin- 
ning over of the wound advances just as it does from the margins. 
In the clinic we have often resorted to this artificial skinning over 
of wounds with epidermis, and rarely ineffectually. The effect is 
perceived when we remove the plaster on the third day and find a 
red aureola around the transplanted piece ; this gradually grows, and 
on the sixth or eighth day is followed by a bluish-white border, just 
as in cicatrization at the edges of the wound. I do not underestimate 
the practical value of this proceeding, but it is even more interesting 
to me from the addition it forms to our knowledge of natural history. 
Here we have the most striking proof not only of the independence 
of cell-life in the tissues of man, but still more of the readily-excited 
formative power of the epithelium, which is here aroused by a change 
of the nutrient material, while the portion of the papillary layer of 
the cutis transplanted at the same time does not grow. 

Thiersch, Minnich, and Menzel have made observations showing 
that, eight hours or perhaps longer after death, epidermis may be 
successfully transplanted. The finer details of the histological 
changes in these transplantations have been carefully studied by 
Heverdin, and still more so by Amabile. Czemy has shown that 
7 



98 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

mucous membrane from the mouth (with flat epithelium) and from 
the nose (with cylindrical ciliated epithelium) may be successfully 
grafted on wounds. [Is this, perhaps, one cause for animals licking 
their wounds ?] The epithelium of these membranes preserves its 
character but a short time, then it is transformed into epidermis. 

[March 6, 1871, Dr. B. Howard presented, at the meeting of the 
New York County Medical Society, a case in which, after skin-grafting, 
cicatrization had progressed for a time, then seemed to be arrested ; 
whereupon he grafted small portions of the biceps muscle and thus 
induced a continuance of the cicatrization. The question was raised 
whether the renewed activity was not due to the previous skin-graft- 
ing. Dr. Stein stated that he had aroused these old ulcers by sprin- 
kling epidermis scales over their surface.] 

Regarding constitutional treatment, we can accomplish scarcely 
any thing with internal remedies in preventing or cutting short the sub- 
sequent fever. Still, certain dietetic rules are necessary. After the 
injury the patient should not overload his stomach, but, as long as 
he has fever, must live on low diet. This he usually does spontane- 
ously, as fever patients rarely have any appetite ; but, even after 
subsidence of the fever, the patient should not live too high, but 
only eat as much as he can digest while lying in bed or confined to 
his chamber, where he has no exercise. If the fever be high, and 
the patient desires some change of drink from cold water, which is 
generally preferred by fever patients, you may order acid drinks, as 
lemonade or some medicinal substance ; the patients soon grow tired 
of the ordinary lemonade ; they bear phosphoric or muriatic acid in 
water with fruit-juice, raspberry-vinegar in water, apple boiled in 
water, toast-water (infusion of toasted bread with some lemon-juice 
and sugar) ; some patients prefer almond-mucilage, water-ice dis- 
solved in water, oatmeal gruel, barley-water, etc. We may give the 
taste of the patient full play ; but it is well for you to attend to such 
things yourself. The physician should know as much about the cel- 
lar and kitchen as about the apothecary-shop, and it is even well for 
him to have the reputation of being a gourmand. 



HEALING BY FIRST AND SECOND INTENTION. 99 



LECTURE IX. 

Combination of Healing by First and Second Intention.— Union of Granulation Surfaces. 
— Healing under a Scab. — Granulation Diseases. — The Cicatrix in various Tissues; 
in Muscle ; in Nerve ; its knobby Proliferation ; in Vessels. — Organization of the 
Thrombus. — Arterial, collateral Circulation. 

To-day I have first simply to add a few words about certain de- 
viations from the ordinary course of healing, which occur so fre- 
quently that they must very often be counted as normal; at all 
events, as very frequent. 

It is not at all unfrequent for the two forms of healing above de- 
scribed, by first and second intention, to combine in the same wound. 
For instance, you unite a wound completely, and may sometimes ob- 
serve that at some places there is healing by the first intention, while 
at others, after removal of the sutures, the wound gapes, and subse- 
quently heals by suppuration. 

But it is much more common for a large and deep wound to heal 
superficially, and to suppurate for some time from the deeper part. 
If the entire surface of the wound be healthy, the cause of the in- 
complete healing is either that it was imperfectly coapted at the 
first dressing, or that blood and exudation escaped between the 
edges, which not only do not coagulate firmly enough to keep up 
the adhesion, but can even decompose and set up an inflammation 
which may spread rapidly and cause severe general disturbances. 
These important results of such wounds compel us specially to study 
their mechanical conditions and chemical changes ; from the first 
they are more or less complete fistulous wounds. 

It may be readily seen that where the skin has been divided, as 
for the removal of a deeply -situated tumor or a portion of diseased 
bone, a cavity is left if the skin is sewed up, which will remain filled 
with air and blood, unless the bleeding has been completely arrested, 
the wound well cleansed, and its edges brought well in contact. In 
cases where different tissues are wounded, and contract unequally, 
as in a wound going down to the bone, the surfaces would be very 
uneven and not be accurately apposed if the edges of the skin were 
simply united. Experience teaches that in such cases large wounded 
surfaces, even if loosely approximated, may be readily separated by 
secondary hemorrhages or fluid exudations, which often decompose 
while the skin above them is completely united. Then the parts 
around the wound swell and become painful, and high fever comes 
on. I will not here describe those dangerous states, septic phleg- 
mon and blood-poisoning, which may arise, but merely say that we 



100 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

may often prevent the development of these processes by early evac- 
uation of the decomposing matter. It is not the mere presence of 
blood between the tissues that causes these affections, for that often 
occurs in severe contusions without wounds and induces no bad re- 
sults ; it is the decomposition of the blood, and the peculiarly phlogo- 
genous and pyrogenous properties of the first exudation, which 
cause the danger. Hence, in treating these wounds, we must take 
care, first, to prevent collection of blood and secretion in the wound, 
and secondly, in case this has not succeeded, to prevent decomposi- 
tion of these fluids, so that they may rest quietly until absorbed, as 
they would if the skin had not been injured. 

Of course, if there be no blood or secretion in the wound, they 
cannot decompose ; hence it is most important to prevent their col- 
lection. This would be most simply prevented by not closing up 
deep wounds, but filling them with charpie, wadding, or similar bib- 
ulous material, after carefully arresting the haemorrhage ; this dress- 
ing must be renewed as often as it becomes saturated. This method 
was used for years, and was considered satisfactory, as no other way 
was known ; still, as we now know better methods, we think the 
reaction was considerable, although less than accompanied the irri- 
tative treatment of the middle ages ; inflammations spreading from 
the wound were frequent, and were referred to individual peculiari- 
ties, then to general influences of the atmosphere or to hospital air. 
It is only within the last twenty years that the propriety of the 
above treatment has been questioned, and new ways, based on differ- 
ent hypotheses, have been sought. This led to two opposite meth- 
ods : one entirely without dressings (open treatment of wounds), 
the other accurate closure and air-tight dressing (method by occlu- 
sion). In the open treatment of wounds, which can only be used 
with facility in wounds of the extremities, the part is so placed that 
the secretion may flow readily into a vessel placed beneath. The 
first two days this secretion is of a dark blood-color and thin ; from 
the third to the fifth day it becomes light brownish, then yellow, and 
soon in the vessel the pus-serum separates from the lumpy flakes of 
pus-cells ; at the ordinary temperature of the room this secretion 
does not begin to smell badly in twenty-four hours, unless consider- 
able quantities of decomposing dead shreds of tissue lie in the wounds 
and pass off with the secretion. This freedom from smell must 
strike any one who has smelt dressings that have been removed from 
a wound after being applied twenty-four hours. The bodily tem- 
perature to which this secretion is subjected while in the dressing is 
doubtless the cause of its more rapid decomposition. Should one 
a priori suppose that with such a dressing collection of the secretion 



.OPEN TREATMENT OF WOUNDS. 101 

with its evil results would be impossible, he will soon find practi- 
cally that the object of the open treatment of wounds will not be 
attained by absolute inattention, but that the form and position of 
the wound may greatly impede the escape of secretion, and also that 
the early, firm union of the skin may shut off certain parts of the 
wound as effectually as if a suture had been introduced, and thus 
the same severe diseases may be induced as by the old methods of 
treatment. In operations we may do much to make wounds of such 
a shape that the secretions will run off at once ; but in accidental 
wounds this is often difficult to do, and requires a certain experi- 
ence. In regard to the above-mentioned formation of pockets, we 
should prevent it by daily breaking up the adhesion, or from the 
first lay drainage-tubes in all the angles and hollows of the wound, 
through which any secretion from the deeper parts may readily es- 
cape. These drainage-tubes, introduced by Chassaignac, are made 
of vulcanized rubber of various calibre, with holes along the sides. 
The term " drainage " is taken from agriculture ; land may be 
drained by laying a system of porous tubes at a certain depth 
through the soil; the water trickles into these tubes, and flows 
through them to large ditches. The results from careful trial of this 
method of open treatment for years far surpassed all previous ones. 
From the publications of JBartscher, Vezin, and JBurow, I had my 
attention called to this plan over ten years ago ; and as it fully 
agreed with the views I had arrived at from clinical and experi- 
mental observations and investigations on the poisonous peculiarities 
of the first secretion from wounds, I have pursued it with particular 
care, and have resorted to it in almost all deep wounds of the ex- 
tremities, whether incised or contused. It was only after being 
assured by some of the most prominent German surgeons that better 
results were obtained by Listens careful antiseptic dressing that I 
would try it, so little did I think of the correctness of the theory. 

There is no doubt that it would be a great advantage for the pa- 
tient and a triumph for surgery if we could without danger induce 
healing by first intention in all large deep wounds. It is true, even 
in the open treatment of wounds, the surfaces may so come in con- 
tact as to heal almost entirely by first intention ; but this is rare, 
although partial adhesions are frequent and do not require breaking 
up if the patient remain free from fever and pain. Formerly, by 
applying bandages to press the surfaces of the wound together, or 
by deep sutures, attempts were made to induce immediate union ; 
although this succeeded in some cases, it proved so dangerous in 
those where the surfaces of the wound were separated by blood or 
exudation, which putrified and could not escape, that conscientious 



102 SIMPLE INCISED WOUNDS OF THE SOFT PAKTS. 

surgeons soon abandoned it. Subsequently, when attempts were 
made by laying strips of oiled rag in the angle of the wound to 
give exit to the secretion, it rarely succeeded. In my opinion Lis- 
ter deserves great credit for having shown that numerous drainage- 
tubes, properly placed in the wound and cut off even with the sur- 
face, will completely carry off all secretion, even if an accurately- 
fitting compressive dressing of bibulous material be applied over the 
united wound ; if, by directly covering the wound with gutta-percha 
or oiled silk, we prevent the drainage-tubes from being stuck up by 
dried secretion, such a dressing has the advantage of an open dress- 
ing, by allowing free escape of secretion, as well as that of a com- 
pressing dressing, by which union of large wounded surfaces is so 
greatly favored. To prevent the escaping secretion from decom- 
posing in the dressing and affecting the wound, the dressing should 
be frequently changed at first. In this care about dressings, as well 
as in cleanliness about operations, it seems to me, lies the great ad- 
vantage of Listens method. But Lister started on the construction 
of his complicated dressing from different ideas ; he thought, just as 
I have repeatedly asserted, that the severe inflammations about 
wounds and the constitutional implications are almost always due to 
decomposition in the wound. I think that decomposition of dying 
tissue and exudation from the wound (for us a decomposition of 
albuminous substances with formation of pyrogenous and phlogoge- 
nous matters) is a chemical process that must, under certain circum- 
stances, always occur in these substances without the addition of 
new agents ; while Lister agrees with Pasteur's view that decompo- 
sition only occurs under the influence of small vegetable organisms, 
just as he claims that fermentation is only developed by yeast fun- 
gus. In regard to this question of living or dead ferments, I must 
refer you to organic chemistry. In physiology you have learned 
about salivary, pancreatic, and gastric ferments, which, although 
produced by cell-activity, no longer act as living organisms, but in 
a purely chemical way. In the same way, I think a substance may 
be formed as the last action of a dying tissue, that shall have some 
of the peculiarities of a ferment, and at the same time have a phlogo- 
genous action, and perhaps be very poisonous for the circulating 
blood. It does not seem to me to have been proved that the addi- 
tion of small organisms (vibriones or bacteria of Pasteur) is abso- 
lutely necessary to the formation of such substances. It is true, 
they are generally found in such fluids ; but this may be explained 
by the fact that these small organisms occur everywhere in air and 
water, and develop particularly in decomposing fluids. 

As we shall often have occasion to speak of these small organ- 



ORGANIC FERMENTS IN WOUNDS. 



103 



isms, whose significance is at present so much discussed, I will here 
give you a brief sketch of those forms that are most frequently found 
in decomposing tissues and fluids. They may be minute spheres 
(micrococcus, from [iLKpbg, small, and 6 ftotacog, the germ), or minute 
rods (bacteria, from to fiafcrripLOV, the rod), which may be isolated, 
in pairs, or in chains of from 4 to 20 links (streptococcus, from 6 
OTpenrbg, the chain, and 6 KOKKog) ; often they are held in the shape 
of a sphere or cylinder by a glutinous substance which they throw 
out (coccoglia, from kokkoc; and rj yXia or yXocd, glue). 



Fig. 17 a. 



° o O °o »<.« 










o*, 



5b 






a, Micrococcus (Monads of Hueter, Microspores of Klebs) ; &, Coccog'lia or Gliacoccus (Zoogloea, 
Cohn) ; c, Streptococcus (Torula) ; d, Bacteria ; e, Vibriones ; /, Streptobacteria (Leptothrix of 
Rallier). Magnified 300-500 

These elements vary greatly in size, from a pale sphere, of such 
diameter that it can scarcely be perceived with the highest power of 
a microscope, to the size of a pus-cell ; they are sometimes mova- 
ble, at others quiet. It is pretty generally agreed that these minute 
organisms are vegetable in their nature, and belong to the algas ; 
but their accurate botanical position and relations to each other are 
still matters of dispute ; their development is not yet explained, 
and until very recently some believed that they were the result of 
generatio cequivoca or abiogenesis, that is, existed without influence 
from any living organism. From my investigations, I think that all 
the above forms belong to one plant, which, being composed of coc- 
cus and bacteria, and being found chiefly in decomposing fluids, I 
have called Coccobacteria septica. This plant seems to me to de- 
velop as follows : first, its germs are found in dry air, and may be 



104 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

recognized under the microscope as fine dust ; placed in water, they 
swell and throw out more or less small pale spheres, micrococcus (a, 
Fig. 21 a). According to external circumstances, these assume the 
following forms : 1. While increasing by segmentation, they throw 
out a slimy cement (glia), by which they hang together in balls, like 
frog-spawn (coccoglia, or gliacoccus, b, Fig. 21 a) ; on the surface 
of fluids this form often appears as coherent bright-brownish mem- 
branes, and it also grows into the interstices of tissues, and is found 
as whitish-gray flakes in fluids ; this form is always without motion. 
Under certain circumstances the glia around these spheres and cyl- 
inders thickens to a membrane, the coccus becomes movable and es- 
capes through an opening in the capsule (ascococcus, from aoicog, 
tube). 2. The coccus divides always in one direction, and some of 
the divisions remain, like frog-spawn, united by a delicate envelope 
of glia (c, Fig. 21 a) ; these streptococci are sometimes in motion, 
wriggling slowly across the field of the microscope, but usually they 
are at rest ; we may find them in fresh secretion from the wound or 
in pus, and often in alkaline urine, without there being necessarily 
any bad odor ; the streptococcus, along with the isolated micrococ- 
cus and gliacoccus, are the forms of coccobacteria which occur most 
frequently in decomposing secretion from wounds or in diphtheria 
of wounds. "With absolute rest the streptococcus may form long 
upright filaments, but this is very rare in living organisms, and is 
difficult to see under the microscope. 3. The coccus grows to 
rods, which increase in length and then divide across ; thus we lave 
bacteria chains (f, Fig. 21 a), which may be moving or motionless. 
In some fluids the division of the bacteria goes on very rapidly, the 
rods becoming shorter, till they are finally square or rounded ; and 
so between coccus and bacteria there are numerous transition forms, 
Bacteria are not apt to enter the secretion from wounds, pus, or 
decomposing blood ; on the other hand, they develop and remain in 
all fluids of the cadaver and in watery exudations of almost all tis- 
sues ; in the latter they are very movable. 

All of these vegetations require plenty of water and organic 
substances, especially nitrogenous matters, for their rapid propaga- 
tion ; they bear abstraction of water up to a certain point, but if 
entirely dried out they die ; and although they will subsequently 
swell if placed in water, they have lost their power of vegetating. 
They can bear temperatures as low as the freezing point, and nearly 
up to the boiling point ; but when it reaches the boiling point they 
die. In fluids or moist tissues completely excluded from atmos- 
pheric air, they will vegetate till all the air contained in the fluid 
has been used up ; then, no more air being absorbed by the fluid, 



ORGANIC FERMENTS IN WOUNDS. 105 

the coccobacteria die, as they cannot canse decomposition of water 
or any organized combination. 

Under these conditions some of these coccobacteria may be 
thrown into the atmosphere and be generally distributed by the 
evaporation of fluids, so common in nature. Still, when the air be- 
comes very dry, these vegetations might dry out, die, and become 
organic but no longer organizable dust ; but such an occurrence is 
provided against. As in many of the algae of stagnant water, hav- 
ing similar peculiarities and subject to being dried out, so in some 
of the elements of coccobacteria a larger quantity of peculiarly con- 
centrated protoplasm unites to form a glistening sphere with dark 
contours, which may be distinguished from other coccus, but hardly 
from fat globules. These little spheres have the peculiarities of 
fungus-germs and very resistant seeds ; thej 7 may be entirely dried, 
cooled far below the freezing and warmed above the boiling point, 
and kept hermetically closed for a long time, without losing their 
germinal activity ; hence they are called permanent germs (JDauer- 
sporen). According to my experience, they form very certainly and 
not very rarely, under certain circumstances, in bacteria ; but they 
also occur in coccoglia balls ; I cannot state whether some spheres 
of streptococcus also become permanent germs. These Dauersporen 
are the dried germs from which we started for development ; they 
require quiet in or on some fluid or moist body. 

I have here given you a brief review of the results to which my 
investigations on this point have led. But I must call attention to 
the fact that botanists have not yet proved the correctness of my 
views, and that they are at variance with those of most others who 
have investigated this subject, and who consider each of the forms 
above described as separate plants, and also make numerous species 
of each kind, especially according to the diseases induced by each. 
Let me also remind you that most pathologists term these algae fungi, 
and often call them all bacteria. 

It is to these small organisms that Pasteur, and after him Lister, 
attributes decomposition, at least those forms of it whose products 
are local and general poisons. If we could prevent their entrance 
into the wound or its secretions, according to this view, there would 
be no decomposition of the secretions, even if some of them did re- 
main in the wound. With this idea, Lister writes a number of rules 
to be followed in the operation and dressing of the wound, all aim- 
ing at the destruction of the germs of coccobacteria which might 
reach the wound through the hands of the operator and assistants or 
the air. After the operator and assistants, before each operation or 
dressing, have carefully washed with soap and water, they dip their 



106 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

hands in a five per cent, solution of carbolic acid ; in the same way 
the parts about the seat of operation are to be carefully washed and 
moistened with the same solution of carbolic acid; and all instru- 
ments, sponges, and dressings used lie in this solution, which is sup- 
posed to kill all germs of coccobacteria. To prevent these germs 
from reaching the wound through the air during the operation and 
dressing, a two per cent, solution of carbolic acid is constantly 
sprayed on the part with a special apparatus, so that it falls on the 
wound in the form of a fine rain. We have already described the 
occlusion or "antiseptic" dressing, as it is termed, although the 
open treatment of wounds and some other methods are just as anti- 
septic. There is no reason for going any further into details here, 
where we are chiefly explaining principles. Listens dressing, which 
seems so complicated, is in practice much simpler than would appear 
from the description ; for every step and rule the inventor had a 
definite reason, and there is nothing arbitrary or intentionally mys- 
terious. If we inquire into the practical working of this treatment, 
we hear chiefly praise, and many speak enthusiastically of its won- 
derful effects. Although my own experience with it is not very 
great, I can recommend it as being generally very good ; it is cer- 
tainly more popular than the open treatment of wounds ; it is still a 
disputed point which of these methods answers best in treatment of 
wounds of the extremities. I urgently recommend you to perfect 
yourselves in the principles and practical application of Lister's 
treatment, and you will have many favorable results. 

It is different if we accurately examine the correctness of the 
theoretical views from which Lister starts, and inquire whether by 
his mode of operating and dressing he has attained his object. In 
regard to the latter point, it has been often proved that in the secre- 
tion of wounds treated according to Listens method, and which healed 
rapidly without reaction, coccobacteria were found about as often 
as in secretion from wounds which were merely dressed with attention 
to cleanliness. This shows : 1, that the presence of these vegetations 
in itself proves nothing about the phlogogenous or other poisonous 
qualities of the secretion ; 2, that Lister's dressing is no guarantee 
for the destruction of bacteria. Against this second point it might 
be urged that there is no proof that these germs reach the wound 
only from without; it is possible that permanent germs enter the 
blood through the respired air, and, though they may not develop 
under normal circumstances, do so in the secretion of wounds. If 
this be possible, there is no sense in the theory of Lister's method 
as far as regards its attacking organic germs by chemical means. 
Indeed, it is my opinion that those not very frequent cases where 



HEALING BY THIRD INTENTION. 10 7 

coccobacteria vegetations have been found in completely closed 
deeply-seated points of inflammation, which never communicated 
with the air, can only be explained in the way above mentioned. 
Apart from the fact that Lister's dressing is expensive if followed 
out in all its details, and that more or less severe poisoning is often 
caused by the annoying dermatitis induced by the carbolic acid, this 
incongruence of theory and practice has led to the employment of more 
and more dilute solutions of carbolic acid, and its replacement by 
other antiseptic and less irritating acids and salts (salicylic acid, 
Thiersch ; sulphide of sodium, Minich). Various changes have 
also been made in the mode of applying the dressing ( Volkmann, 
Bardeleben) ; the spray has been entirely omitted, and in its place 
after the operation the wound has been washed with a more concen- 
trated antiseptic solution, etc., etc. Thus Lister's dressing has 
been variously modified, and from each modification the same favor- 
able results have been obtained as from the original dressing. This 
confirms me in the opinion formed when this method was first de- 
scribed, and which I have already stated, that the scrupulous clean- 
liness and the careful removal of secretion from the wound is the 
most important part of it, and that it is chiefly popular among sur- 
geons who formerly paid less attention to these points, and left the 
dressings to the dirty hands of nurses or to careless students or 
young physicians, while now the dressings are all applied according 
to definite principles of cleanliness. Moreover, the constantly 
spreading and more energetically preached doctrine of local infection 
from wounds, of which we shall treat hereafter, has led to a rec- 
ognition of the necessity of a rational treatment of wounds, and 
has contributed essentially to opening the way for the open treat- 
ment of wounds — to Lister's method and antiseptic lotions. 



There is still another mode of adhesion of the edges of wounds, 
which consists in the direct union of two adjacent granulating sur- 
faces. This mode of healing, which you may call healing by the third 
intention, is unfortunately very rare. The reason of this is evident : 
pus is constantly secreted from the surface of the granulations, and 
while this goes on the surfaces are only apparently in contact, for 
there is pus between them. Occasionally, it is true, we may, by press- 
ing the two granulation surfaces together, prevent the further forma- 
tion of pus, and then the two surfaces may adhere ; we accomplish this 
by drawing the flaps of the wound firmly together with good adhesive 
plaster, or by the application of secondary sutures, for which it is well 
to employ wire. Unfortunately, the attempt to hasten the cure by 



108 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

these means so rarely succeeds, that they are only exceptionally em- 
ployed. The best results are obtained from secondary sutures when, 
six or seven days after the injury, they are applied about four or five 
lines from the edge of the wound, because the tissue is then more 
dense and firm, and the sutures cut through less quickly. 

There is still another mode of healing, viz., healing of a superficial 
wound under a scab. This only occurs frequently in small wounds, 
that secrete but little pus, for in these alone does the pus dry on the 
wound to a firmly-attached scab ; in profuse suppuration it is true the 
superficial layer of the pus may dry by evaporation of the watery 
portion, but, while new pus is constantly being secreted under it, it 
cannot form an adherent, consistent scab. When such a scab has 
formed, the granulation tissue develops to only a very small amount un- 
der it ; perhaps because on account of the slight pressure of the scab, the 
granulation tissue is less mucous, so that the epidermis can more 
readily regenerate under the scab ; such a small wound may be wholly 
cicatrized when the scab falls. 



The granulation surface may assume a totally different appearance 
from that above described, especially in large wounds. There are 
certain diseases of the granulations, whose marked forms I shall 
briefly sketch for you, although the varieties are so numerous that you 
will only learn them from individual observation. We may divide 
granulation surfaces as follows : 

1. Proliferating fungous granulations. The expression " fungous ' 
means nothing more than " spongy ; " hence by fungous granulations 
we mean those that rise above the level of the skin, and lie over the 
edges of the wound, like fungus or sponge. They are usually very 
soft ; the pus secreted is mucous, glairy, tenacious ; it contains fewer 
cells than good pus, and most of the pus-cells, like granulation-cells, are 
filled with numerous fat-globules and mucous material, which is also 
more abundant than normal as intercellular substance ; and in these 
granulations Mindfleisch also discovered collections of Virchoufa 
mucous tissue, fully developed. The development of vessels may be 
very prolific ; the fragile tissue often bleeds on the slightest touch ; 
occasionally the granulations are of a very dark blue. In ofher cases 
the development of vessels is very scanty, often to such a degree that 
the surface is light red, or in spots has even a yellowish, gelatinous 
appearance, in very anaemic persons, often also in young children and 
very old persons. The most frequent cause of development of such 
proliferating granulations is any local impediment to the healing of 
the wound, such as rigidity of the surrounding skin, so that the con 



DISEASES OF THE GRANULATIONS. 109 

traction of the cicatrix is difficult ; a foreign body at the bottom of a 
tubular granulating wound (a fistula) ; this abnormal proliferation is 
also particularly apt to occur in large wounds, which can only contract 
slowly ; it appears as if the activity of the tissue was occasionally ex- 
hausted, and no longer capable of continuing the requisite condensa- 
tion and cicatrization, so that it only produces relaxed, spongy granu- 
lations. As long as there are granulations of the above character, 
rising above the edges of the skin, cicatrization does not usually pro- 
gress. The wound would probably heal, but not for a very long time. 
We have plenty of remedies for hastening the healing under such cir- 
cumstances ; these are especially caustics, by which we partly destroy 
the granulation surface, and thus excite a stronger growth from the 
depth. At first you may cauterize the granulating surface daily, es- 
pecially along the edges, with nitrate of silver, whereupon a white 
slough will quickly form, which will become detached in twelve to 
twenty-four hours, or even sooner; repeat this cauterization as re- 
quired, till the granulating surface is even. Another very good rem- 
edy is sprinkling the wound with powdered red precipitate of mercury . 
(hydrar. oxyd. rubrum), which also should be repeated daily, to im- 
prove the granulating surface. Compression with adhesive plasters 
also acts very well occasionally. If the granulations be exceedingly 
dense and large, we often may succeed soonest by cutting some of 
them off with the scissors ; the consequent haemorrhage is readily 
arrested by applying charpie. Where the proliferation is less, as- 
tringent lotions, such as decoction of oak-bark, cinchona-bark, lead- 
water, etc., may answer to excite the sluggish cicatrization. 

2. By erethitic granulations we mean those characterized by great 
pain on the slightest provocation ; they are usually very proliferant 
granulations, which readily bleed; it is a very rare condition. In 
excessive erethism of the granulations, they are so sensitive that they 
cannot endure the slightest touch or any dressing ; a less degree of sen- 
sitiveness of the granulations is not so rare. On what it depends, is not 
very certain ; granulation tissue itself has no nerves ; in most cases 
touching it causes no sensation, only the conduction of the pressure to 
the subjacent nerves causes sensation. In the above excessive sensibil- 
ity, probably the ends of the nerves at the floor of the wound are degen- 
erated in a peculiar manner ; perhaps there are miniature thickenings 
of the finest nerve-ends, like those that we shall hereafter see on large 
nerve-trunks. It would be a thankworthy task to make a careful ex- 
amination of this question. We occasionally observe similar condi- 
tions in the cicatrices in large nerves, and shall speak of this hereafter. 
For this very painful sensitiveness, which not only interferes with 
healing, but greatly worries the patient, you may first try soothing 



110 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

ointments, almond-oil, spermaceti-ointment, or simple cataplasms of 
boiled oatmeal or linseed-meal, or warm-water compresses. The nar- 
cotic compresses or cataplasms, made with the addition of belladonna 
or hyoscyamus-leaves, are of little benefit. If these applications do 
not answer, do not delay destroying the entire granulating surface, or 
at least the painful part, with caustic (nitrate of silver, caustic potash, 
or the hot iron), with the patient anaesthetized, or else excising the 
entire surface with the knife. If the great painfulness be due to hys- 
teria, anaemia, etc., you will not attain much by any local remedies, 
but should try to assuage the general irritability by internal remedies, 
such as valerian, assafcetida, iron, quinine, warm baths, etc. • 

3. In large wounds, especially in fistula granulations, a yellow rind 
sometimes forms on part of the granulation surface, which may be 
readily detached, and on careful examination is found to consist of pus 
cells, very firmly attached together. Although I have sometimes 
found coagulating filaments between the cells, they do not always 
occur, hence we must suppose that the cell-body, the protoplasm itself, 
is transformed into fibrine, as occurs in true croup, and especially in the 
formation of fibrinous deposits on serous membranes. Here there is 
also a croup of the granulations. The croupous membrane reforms 
even a few hours after its removal, and this is repeated for several . 
days, till it either disappears spontaneously, or finally ceases on cau- 
terization of the affected part. Very similar white spots are occasion- 
ally found on larger granulation surfaces, which are probably not 
caused by fibrinous deposits, but by local obstruction of the blood- 
vessels. Under peculiar, unfavorable conditions, both states may re- 
sult in destruction of the granulations, in a true diphtheria of the 
wound, which we shall hereafter treat of as hospital gangrene. For- 
tunately, however, it rarely goes on to this disease, but the state of 
the wound improves again after a time, and the recovery takes the 
usual course. 

If disease of the granulating surface be accompanied by swelling, 
great pain, and fever, we have a true acute inflammation of the wound; 
then the mucous granulation substance sometimes coagulates through- 
out to a fibrinous mass ; the wound-surface looks yellow and greasy. 
I shall treat of the causes of these secondary inflammations under the 
head of contused wounds. Usually the croupous inflammation, which 
has affected part or the entire surface of a wound, ends in sloughing 
of the diseased granulations, whereupon new granulations spring from 
the depths. 

It cannot be denied that the perfectly local, superficial, and inter- 
stitial deposit of fibrine strongly supports the view that Virchow 
has proposed for croupous processes generally. It was formerly sup 



DISEASES OF THE GRANULATIONS. m 

posed that in all inflammatory croupous process, especially in the 
ordinary form of acute inflammation of the lungs and pleura, the 
blood was over-rich in fibrine ; that there was a fibrinous crasis in the 
blood, as a result of which, the excessive fibrine escaping from the 
capillaries, coagulates partly on, partly in, the inflamed surface, and 
so led to the formation of these pseudomembranous deposits. ~Vir- 
chow, on the other hand, proposed the idea that, by the inflammatory 
process, the tissue may be placed in a condition to cause coagulation 
of the fibrinous solution infiltrating it. I cannot here enter more par- 
ticularly into the various grounds on which Virchow bases this view, 
but shall only call attention to the fact that in the case in question 
(of fibrinous exudation on the granulating surface), at least there can 
be no rapidly coming and evanescent fibrous crasis of the blood ; but 
evidently it is a local process which may readily be removed by local 
remedies. According to the repeatedly-mentioned observations of 
A. Schmidt, we may infer that in certain quantitative and qualitative 
irritations of the tissue, more fibrogenous tissue than usual escapes 
from the capillaries. Virchow had even previously called attention 
to the fact that, from repeated irritation, simple serous exudation may 
become fibrinous or croupous. If you apply a spanish-fly blister to 
the skin, a vesicle filled with serous fluid forms — the superficial layer 
being lifted from the rete mucosum by the rapidly-forming serous exu- 
dation ; if we remove the vesicle and reapply the blister, in many . 
cases after a few hours we shall find the surface covered with a fibrin- 
ous layer, which contains innumerable newly-formed cells ; indeed, is 
almost entirely composed of them. We may attain the same result by 
applying the plaster to skin already inflamed, or to a young cicatrix. 

The treatment of croupous inflammation of the granulations is 
purely local ; we should carefully seek for any causes of new irrita- 
tion, and try to remove them. Daily remove the fibrinous rinds, and 
cauterize the exposed surface with nitrate of silver, or paint it with 
tincture of iodine, and you will soon see this abnormal state of the 
granulating surface disappear. 

4. Besides the above diseases of the granulations, there is occa- 
sionally a state of perfect relaxation and collapse, in which they pre- 
sent an even, red, smooth, shiny surface, from which the nodular, 
granular appearance has entirely disappeared, and, instead of pus, a 
thin watery serum is secreted. This state almost always occurs in 
the granulations at the end of life ; as already mentioned, you always 
find it in the cadaver. 

It is still necessary to add something about the cicatrices, con- 
cerning certain subsequent changes in them, their proliferation and 
their shape in different tissues. 



112 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

Linear cicatrices of wounds, that have healed by first intention, 
rarely undergo subsequent degeneration. Large, broad cicatrices, 
especially when they lie immediately on the bone, often open again ; 
the epidermis, which is tender at first, being torn off by motion or by 
the least blow or friction, and there is superficial atrophy, an excoria- 
tion of the cicatrix. Sometimes the young epidermis is elevated like 
a vesicle, by exudation from the vessels of the cicatrix; there may 
also be some haemorrhage, so that the vesicle will be filled with bloody 
serum. Then, after removing the vesicle, you have an excoriation, as 
after simple rubbing off of epidermis. This opening of the cicatrix, 
if often repeated, may prove very annoying to the patient. You pre- 
vent this most readily by causing the patient to protect the young 
cicatrix for a time with wadding or a bandage. If the excoriation 
nas taken place, apply only mild dressings : oil, glycerine, zinc-salve, 
etc., or emplastrum cerussa. In these cases, irritating salves enlarge 
the wound, and consequently should be avoided. 

If the granulating surface be once perfectly covered with epider- 
mis, as already stated, the retrogressive changes to solid connective 
tissue take place in the cicatrix, and it atrophies. But in rare cases 
the cicatrix grows independently, and develops to a firm connective- 
tissue tumor. This is seen almost exclusively in small wounds that 
have long suppurated and been covered with spongy granulations, 
over which the epidermis formed exceptionally. You know it is the 
custom to pierce the ear-lobes of little girls, so that they may subse- 
quently wear ear-rings. This little operation is done with a coarse 
needle by the mother or the jeweller, and a small ear-ring is at once 
introduced through the fresh puncture. As a rule, this puncture soon 
heals — the ring preventing the closure of the opening. But in other 
cases there are active inflammation and suppuration ; indeed, if the 
suppuration continue, the ring may cut downward through the lobe ; 
granulations develop at the openings of entrance and exit ; finally, 
the trial is given up, and the ring removed ; then the opening often 
heals quickly. In other cases the granulations cicatrize, the cicatrix 
continues to grow, and on both sides of the lobe of the ear small 
connective-tissue tumors, small fibroids, form. These look like a thick 
shirt-button drawn through the hole of the ear, and they grow inde- 
pendently like a tumor. If you examine these tumors, on section 
you find them of pure white tendinous appearance, like the cicatrix 
itself. Microscopically the tissue is found to consist of connective 
tissue with numerous cells ; it is simply a proliferation, an hypertrophy 
of the cicatrix. I have seen this twice in the ear ; another case is 
mentioned by Dieffenbach in his operative surgery. I once saw 
similar tumors on the back of the neck, where they had formed at the 



CHANGES IN CICATRICES. 



113 



openings made for a seton ; they were about the size of a horse- 
chestnut. They should be carefully removed with the knife, and any 
subsequent granulations kept in subjection by nitrate of silver. 

[The translator has seen the above tumors on the lobe of the ear 
several times ; in all but two instances they occurred in mulatto 
females ; in one case the tumor had returned after a previous re- 
moval.] 

In the above description of the formation of granulations and cica- 
trices, for the sake of simplicity we have only referred to the process 
as it is found in connective tissue, but must now speak of it as it 
occurs in cicatrization of other tissues. 

The cicatrix in muscle is at first almost entirely connective tissue ; 



Fig. 18. 




Cicatrix from the upper lip of a dog. «, connective tissue of the cicatrix. The divided muscular 
fibres are here atrophied for a short distance, and terminate in a conical shape. Magni- 
fied 300 diameters. 



in the ends of the muscular fibres there is at first destruction, then at 
a certain boundary a collection of nuclei ; then there is rounding off 
of the fibres, sometimes club-shaped, sometimes of more conical form, 
and the stumps of the muscular fibres unite with the connective tissue 
of the cicatrix just as they do with the tendons ; the muscle cicatrix 
becomes an inscriptio tendinea. I myself have only observed them in 
wounds of muscle that had healed by first intention, and have never 
there seen any thing that I could decide was a new formation of mus- 
cular tissue. In suppurating ends of muscle, 0. Weber has witnessed a 
slight formation of new muscle ; this appears to occur chiefly in for- 
mation of granulations on muscle and in certain tumors. 

Weber is of the opinion that young muscular fibres typically form 
8 



114 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



from the cells of old ones, but considers it impossible to prove that no 
muscular cells originate from other young cells. As a result of his 
examination of old muscular cicatrices, he also maintains that the re- 
generation continues a long time, and in most cases is more complete 
than is generally supposed. Maslowshy has affirmed the metamor- 



Fiq. 19. 




Ends of divided mascular fibres from the biceps muscle of a rabbit eight days after the injury; 
a be, old muscular fibres; a, the contractile substance rolled up and balled together; the 
same way in the bundle above d; the same with the sarcolemma drawn out to a point; c, 
into the pointed cornet-shaped sarcolemma tube extends a series of young muscular nuclei, 
between which there is very delicate transversly striated substance; e, the same with 
young, free muscle-cells ; /, two young ribbon-like muscular filaments ; g, the same of vari- 
ous size isolated. Magnified 450 diameters ; after 0. Weber. 



phosis of wandering cells to muscle-cells ; but I consider the cinnabar 
method employed by him as insufficient to prove this assertion. [Cin- 
nabar or vermilion injected into the blood is taken up by white cor- 
puscles, and may afterward be discovered on inflamed tissue.] 

Gussenbauer has shown that, after injury, the muscular filaments 
usually break down into flakes, and then new young muscle-cells 
form, after the type of embryonal development, from the cells con- 
tained in the old muscle-filaments ; the amount of the new formation 
depends on the quality and duration of the irritation. 

If a nerve be divided, its ends separate, from their elasticity, they 
swell slightly, and subsequently unite by development of a new forma- 
tion of true nerve-tissue, so that the nerve is again capable of conduc- 



CICATRICES IN MUSCLES AND NERVES. 115 

tion through the cicatrix. In large superficial cicatrices, new nerves 
develop ; when you have excised portions of skin and have brought to- 
gether and united parts lying at a distance, new nerves grow through 
the cicatrix and perfect power of conduction comes after a time, as 
may be often observed in plastic operations. These facts are very 

Fig. 20. 




Regenerative processes in transversely-striated muscular fibres after injury. Magnified about 500, 

after Gussenbauer. 

remarkable, and physiologically are still entirely inexplicable. Just 
think how wonderful that these nerve-filaments, sensory and motor, 
should find each other in the new adhesion, and that even, as we must 
suppose, the stumps of the primitive fibres should unite as they had 
been united, so that correct conduction and localization might result 
as they actually do ! We cannot here go more exactly into this sub- 
ject. I will only mention that the more minute process, which has 
been very carefully followed by Schiff, Hjelt, and others, is generally 
as follows : first, in the stump of the nerve there is a destruction of 
the nerve-sheath, possibly also of the axis cylinder to a certain extent ; 
at the same time in the neurilemma there is a collection of cells, 
which proceeds to the development of spindle-shaped cells in the sub- 
stance lying between the ends of the nerve, and extending into the 



116 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 




stump. From these cells, just as in the embryo during intra-uterine 
life, new nerve- fibrillae develop upward and downward; the filaments, 
which are at first very pale, subsequently acquire a sheath, and then 
cannot be distinguished from ordinary nerve-filaments. 

The most recent 
FlG - 21 - Fig. 22, investigations as to 

the significance of 
wandering cells in 
new formation of tis- 
sue, as well as the 
special studies over 
the formation of 
nerves in portions of 
tadpoles' tails regen- 
erated after injury, 
have made me doubt 
the former view, that 
young regenerated 
nerve-filaments were 
composed of spindle- 

Kegeneration of nerve?. Fig. 21, from a rabbit fifteen days after Cells. It Seems to me 
division ; young spindle-cells in the end of the nerve developed , , ,, 

from the connective tissue aDd intimately connected with the much more probable 
neurilemma. Fig. 22, from the frog ten weeks after division; ,i , .1 A' 'A A 
development of young nerve-cells from the spindle-cells. Mag- tnat tne CUVlQeQ axis- 
nified 306 diameters, after Hjelt. cylinders grow out in- 

to young nerve-filaments, and that the elongated spindle-cells, which 
undoubtedly exist in the nerve-callus in certain stages, either belong 
to the connective tissue of the neurilemma or are detached portions 
of young nerve-filaments containing nuclei. 

The last investigations of Neumann and Eichhorst confirm pre- 
vious ones in regard to the immediate results of division, but show 
that the young nerve-filaments grow directly from the axis-cylinder, 
as well from the central as from the distal part, meet together, and 
blend, as the offshoots from a capillary wall sink into the wall of 
another vessel, and so may form a communicating canal between two 
vessels {Arnold). The process in the wounded nerve corresponds 
most beautifully with that in wounded muscle. In the muscular as 
in the nervous filament several young filaments sprout from one 
primitive filament [a, Fig. 22 A ; compare Fig. 20). 

So it is shown that muscles, vessels, nerves, and epithelium- are 
not regenerated from proliferating connective-tissue cells or wan- 
dering cells, but from throwing out offshoots from their tissue, or 
from cells derived from the protoplasm of their tissue. It is very 
probable that connective-tissue cells also, especially those still con- 



CICATRICES IN MUSCLES AND NERVES. 



117 



taining protoplasm, send out offshoots at the wounded part in which 
nuclei subsequently form, as is done in the nerves of the tadpole's 
tail. This point should be investigated again ; till then we may re- 
gard wandering cells as the source of the young regenerated tissue. 
Since Schwann's teaching about the development of tissue from 
cells, we are so convinced that every new tissue proceeds from young 
cells, that the announcement of independent growth of a perfect 
tissue without intervention of cells finds little credit ; and the increase 




Nerve of a rabbit: a, seventeen days after division; 6, fifty days; c, frog's nerve, thirty days 
nified about 600. After Mchhorst. 



Mag- 



of cells by offshoots, with subsequent development of nuclei in these 
offshoots, is a procedure that histologists have long kept in the 
background, substituting for it cell-division, although botanists have 
ascribed a very prominent r61e to this mode of development in 
plants. From' the latest published observations we see that the 
capillary walls, the axis-cylinder of nerves, and the contents of mus- 
cular filaments possess this capacity for outgrowth without direct 
participation of new cells. Rohitansky ascribed to connective tis- 
sue the capacity for independent outgrowth. 

Tn the human being the regeneration of nerves only takes place 
within certain limits, which, it is true, cannot be very accurately de- 
fined. The complete regeneration of large nerve-trunks, as of the 
sciatic or median nerves, does not occur ; nor does it take place after 
excision of large portions of nerve, if the ends remain, say three or 
four lines apart. Very accurate apposition of the ends of the nerve 
is necessary, for apparently the transformation of the newly-formed 
intermediate substance to nerve-substance can only take place by 
means of the nerve-stump, although there are different opinions about 



118 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

the mode of this process ; we shall see similar conditions in the heal- 
ing of broken bones, where bony union only follows accurate coapta- 
tion of the fragments. Now, how is it in this respect with brain and 
spinal tissue ? In the human being there is no regeneration here 
after injury, or after loss of substance from idiopathic inflammation, or 
at least not sufficient to restore the power of conduction. In animals, 
indeed, as Mrown-Sequard has shown in pigeons, after dividing the 
spinal marrow, there may be regeneration with disappearance of the 
paralysis, which has of course occurred in all parts below the point of 
division. Unfortunately, this power of regeneration of nerves decreases 
in proportion to the higher development of the vertebrate animals, 
and it is least in man. As is known, in young salamanders whole 
extremities grow again when they have been amputated. "What a 
pity this is not so in man ! However, as regards the nerves, Nature 
occasionally seems to make a fruitless attempt at regeneration ; for 
quite often the nerve-ends in amputation-stumps, instead of simply 
cicatrizing, develop to club-shaped nodules, which are occasionally ex- 
cessively painful, and require subsequent excision. These nodules on 
the nerves consist of an entanglement of the primitive nerve-filaments, 
which develop from the stump of the nerve as if they would grow to 
meet opposite nerve-ends. The cicatrices in the continuity of nerves 
also are sometimes nodular from the formation of convoluted primitive 
filaments. Such small nerve-tumors (true neuromata) are occasion- 
ally excessively painful, and must be removed with the knife. But 
there are also traumatic neuromata, which are not at all painful, as I 
have seen in old amputation-stumps. In general, these proliferations 
of nerve-cicatrices are to be compared with the previously-mentioned 
hypertrophy of connective - tissue cicatrices, and with proliferating 
bone, which, although rarely, is formed in great excess in the healing 
of broken bones. 

The process of healing after injury of great vessels, especially of 
arterial trunks, has been carefully determined by experiment. If a 
large artery be ligated in an amputation or for disease in its continu- 
ity, as the ligature is drawn tight, the tunica intima is ruptured, and 
the tunica muscularis and adventitia are so constricted that their inner 
surfaces folded up lie in exact apposition. You may satisfy yourselves 
of the frequent although not necessarily universal rupture of the in- 
ternal tunic, by ligating a large arterial trunk in the cadaver, for you 
not unfrequently experience a slight grating or crackling under the 
finger when tightening the ligature ; you may also see it on cutting 
open a ligated artery after detachment of the ligature. From the 
point of ligation to the next branch leaving the artery, both at the cen- 
tral and peripheral ends, the calibre of the vessel fills with coagulated 



FORMATION OF THROMBUS. 



119 



Pio. 28. 




Nodular nerve-terminations in an old amputation-stump of the arm. From a preparation in 
the Anatomical Museum at Bonn. Copied after Froriep, " Surgical Copperplates." Bd. I., 
Taf. 113. 



blood, the so-called thrombus (from 5 $pofi(3og, the blood-clot). The 
enveloping ligature kills the enclosed tissue, which gradually breaks 
down into pus, and when this process is completed the ligature falls, 
or, as we technically express it, " the ligature has cut through," " comes 
away." When this has taken place, the calibre of the artery must be 
permanently and certainly closed, or there will at once be another 
haemorrhage. Under unfavorable circumstances it may certainly happen, 
in small as well as in arteries of medium or large size, that the ligature 
cuts through too soon, and then dangerous, sudden secondary haemor- 
rhage occurs. We may foresee this if the wall of the artery was dis- 
eased ; often calcined arteries cannot be ligated, as the ligature does 
not compress them or cuts through them at once ; sometimes the ar' 
tery is softened (as, for instance, when part of its course has been 
through the wall of a large abscess) so that on ligation the ligature 
cuts through and must be applied farther up. But unfortunately, in 
perfectly healthy subjects, as I found in the last war, haemorrhages 
too often occur from the point of ligation of large arteries, where 
carefully-applied ligatures cut through before the organic closure was 
firm enough to resist the current of blood ; this greatly impairs the 
value of such operations, which are often temporarily necessary to 
save the patient's life. 



120 



SIMPLE INCISED WOUNDS OF THE SOFT PAKTS. 



Fig. 24. 



Artery ligated in the 
continuity. Throm- 
bus; after Froriep. 



Passing now to the consideration of what has taken place in the 
end of the vessel from the coagulation of the blood till the firm closure, 
experiments on animals and accidental observations 
on man have given the following : the blood-clot at 
first lying loose in the vessel gradually becomes more 
firmly attached to the wall of the vessel, and con- 
stantly grows harder, but still remains red for a long 
time ; it does not lose its color for weeks or months, 
and then does so first in the centre, so that the rest 
of it still retains a slight yellowish tinge. After the 
detachment of the ligature, the thrombus is so hard 
and so firmly attached to the walls of the vessel 
that the calibre is entirely closed. The preparation 
(Fig. 24) shows you the thrombus formation in an 
artery after ligation in the continuity; the lower 
thrombus reaches to the point of departure of the 
first branch, the upper one not so far ; the former is 
the rule as laid down in most books, the latter is a 
not uncommon exception. Plugging of the artery 
by a blood-clot, which becomes firm, is, however, only 
a provisional state, for the thrombus does not remain so for all future 
time, but the cicatricial tissue shrinks and atrophies ; this takes place 
in the course of months and years, at which time the closure of the 
artery at the point of division has become solid by adhesion of the 
walls of the vessel. If you examine such an artery a few months after 
the ligation, you find nothing of the thrombus ; but the artery termi- 
nates in a conical point of cicatricial connective tissue. 

The above changes, which we may follow with the naked eye, 
show that in the blood-clot there is a change which essentially consists 
in its increasing firmness and coherence to the wall of the vessel ; we 
shall now study with the microscope on what this transformation of 
the blood-clot depends. If you examine the recent blood-clot, you 
find it to consist of red blood-corpuscles, a few colorless blood-cells, 
and of fine filaments and coagulated fibrine, arranged in irregular net- 
work. If you take a thrombus two days after the ligation of a small 
or medium-sized artery, it is firmer than at first, and is broken up with 
difficulty; the red blood-cells are little changed, the white ones are 
greatly increased ; they have sometimes two and three nuclei as pre- 
viously, sometimes single pale, oval nuclei with nucleoli; some of 
these cells are almost double the size of white blood-cells. The fine 
filaments of the fibrine are united to an almost homogeneous mass, 
which is difficult of division. If you again examine a thrombus six 
days old, the red blood-cells have almost disappeared, the fibrine is 



FORMATION OF THROMBUS. 121 

more firm and homogeneous, and even more difficult to separate than 
previously ; a large number of spindle-shaped cells with oval nuclei, 
showing distinct divisions, appear. From the above, it appears 
that even quite early a number of living cells appear in the blood- 
clot, whose further development will be seen from what follows. 
Since we obtain a more accurate understanding of the changes in the 
thrombus and its relation to the arterial walls, by making transverse 
sections of the thrombosed artery, we shall proceed to do this. 

This preparation shows a transverse section of a recent throm- 
bus in a small artery; within, the delicate mosaic formed by the crowded 

red blood-corpuscles, among them a 
FlG - 25 - few round white blood-cells (which 

have been rendered visible by car- 
mine) ; next comes the tunica intima, 
laid together in regular folds, in 
which the blood-clot clings ; then the 
tunica muscularis ; then the tunica 
adventitia, with the net-work of elas- 
tic fibres ; to the right some adherent 
loose connective tissue. The next 
preparation (Fig. 26) is the transverse 
section of a human artery, closed with 
a thrombus for six days ; we see no 

Transverse section of a fresh thrombus. „ i ui^^j „«n„ . +1,^ „t1^+« ^„™ „„^ 

Magnified 300 diameters. red blood-cells ; the white ones are 

greatly increased, mostly round ; but, 
in the tunica adventitia and surrounding connective tissue, there has 
already been some cell infiltration. If we now examine a ten-day-old 
thrombus from a large muscular artery of the thigh of a man (Fig. 27, 
a), we find it already containing numerous spindle-cells, which are partly 
arranged in striae (subsequently vessels) ; the intercellular substance 
is filamentary, here rendered transparent by acetic acid. Finally, there 
is also formation of blood-vessels in the organized thrombus, as you 
see in the following preparations (Figs. 28 and 29). 

It has been established, by the investigations of 0. Weber, that 
the vessels of the thrombus communicate partly with the calibre of 
the thrombosed vessel, partly with its vasa vasorum. 

The process of healing in transversely-divided veins appears at 
the first glance to be much simpler than in the arteries ; even in the 
large veins of the extremities, the divided ends fall together, and ap- 
pear to heal at once, as soon as the blood has been obstructed at the 
next valve above ; at these valves clots form, and they are often much 
larger than is desirable ; this formation of clots extending toward the 
heart will hereafter occupy our earnest attention. But I have of late 




122 



SIMPLE INCISED WOUXDS OF THE SOFT PARTS. 



observed that the tunica intima of the divided vein does not by any 
means so fold together and adhere, but that here also there is a clot, 
although a small one, which is organized like the arterial thrombus. 



Fick 26. 




Transverse section of a thrombus six days old. 300 diameters. 



Fio. 27. 




Ten-day-old thrombus, a. Organized thrombus ; b. Tunica intima ; c, Tunica muscularis ; d, 
Tunica adventitia. 300 diameters. 



FORMATION OF THROMBUS. 



123 



If you draw conclusions from these preparations, presented in such 
a fragmentary way, it appears that in the clotted blood there is a cel- 
lular infiltration, which here leads to development of connective tissue ; 
in short, that the thrombus becomes organized. The thrombus is not 
a permanent tissue, but gradually disappears again, or, at least, is re- 
duced to a minimum, a fate which it shares with many new formations 
resulting from inflammation. 



Fig. 28. 




Completely-organized thrombus in the human arteria tibialis postica. a, Thrombus with ves- 
sels, perfectly united with the innermost layer of the intima; &, the lamellae of the tunica 
intima; c, the tunica muscularis, traversed by numerous connective tissue and elastic fila- 
ments ; d, Tunica adventitia. Magnified 300 diameters. After Bindfleisch. 



Peculiar reasons caused me to investigate more accurately the or- 
ganization of the thrombus. The importance of this process is rather 
extensive ; a point on which you cannot at present judge well, but 
will hereafter be in a position to estimate fully, when we come to 
treat of diseases of the vessels. 

From my investigations up to the present time, I do not think I 
dare retract the assertion that coagulated fibrine may, by aid of cells, 
be transformed into connective-tissue intercellular substance, although 
I cannot decide whether this be due to true metamorphosis, or to a 
gradual substitution of cell protoplasm for disappearing fibrine. Some 
have attempted to refer the origin of the cells, which appear in con- 



124 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

stantly-increasing numbers in the thrombus, to the wall of the vessel; 
the arteries, as well as the veins, are coated with a lining of epithe- 
lium, which to some extent represents the innermost lamella of the 
tunica intima. These epithelial cells and the nuclei of the striated 

Fig. 29. 




Longitudinal section of the ligated end of the crural artery of a dog, fifty days after ligation ; 
the thrombus is injected; a a, tunica intima and media; b b, tunica adventitia. Magnified 
40 diameters. 

lamellae of the intima have been claimed a priori by some authors, so 
that they could let new cells be formed from them, and grow into the 
thrombus ; in his last work, Thiersch also inclines to this view. I 
acknowledge that I myself formerly strongly combated the supposi- 
tion that the blood could of itself become organized to connective 
tissue with vessels ; but from examinations of transverse sections of 
thrombosed arteries, I am satisfied of its correctness. After having 
abandoned the idea of proliferation of stable tissue-cells in inflamma- 
tion, we can no longer talk of a proliferation of the intima in the old 
sense. But whence come, then, these newly-formed cells ? I have no 
doubt that they originate from the white blood-cells, which have been 



FORMATION OF THROMBUS. 

Fig. 30. 

a I 



125 




Portion of a transverse section of a human femoral vein, with an organized vascular thromhus, 
18 days after amputation of the thigh ; a a, Tunica intima j b b, media ; c c, adventitia ; d d % 
enveloping cellular tissue ; Th, organized thromhus with vessels ; the layering of the 
fibrine is still distinctly visible in the periphery of the thrombus. Magnified 100 diameters. 

partly enclosed in the thrombus, partly may have wandered into it, 
according to the observations of Fi Recklinghausen and JBubnoff. 
As regards the red blood-cells, it seems that they gradually unite with 
the coagulated fibrine, lose their shape, become intercellular substance, 
and lose their coloring matter, which is separated as granules or crys- 
tals of hematoidin. Little as we know whence blood-cells come, and 
whither they go, still it is certain that the white cells enter the blood 
from the lymphatic vessels, and that they enter the latter from the 
lymphatic glands or connective tissue elsewhere ; they are cells that 
originate directly from connective-tissue cells, or from a protoplasm 
analogous to connective tissue. Are these cells still viable when en- 
closed in a blood-clot ? After coming to rest here, can they transform 
themselves to tissue ? It is impossible to affirm or deny these 
questions absolutely ; since Bubnoff has shown that wandering cells 
enter the thrombus, and may there continue their movements, there 
is no necessity for supposing that the white blood-cells (which are 
identical with wandering cells) enclosed in the thrombus, on coagula- 



126 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 

tion, no longer move, and cannot be transformed into tissue. Hith- 
erto there have been no investigations as to whether wandering cells 
pass through the walls of arteries as readily as through those of veins, 
as JBubnoff^s investigations only refer to venous thrombi. Some of 
my investigations in this direction showed me that minute cinnabar 
granules passed through the carotid of a dog into the thrombus, but 
I could not satisfy myself that they were replaced by wandering cells. 
So at present it is uncertain whence the numerous wandering cells in 
an organizing arterial thrombus originate, and how they enter there. 
Tschausoff) in a very carefully-studied work that has lately appeared, 
calls attention to the fact that a great portion of large thrombi are 
destroyed by disintegration. This is very true, but he goes too far 
when he entirely denies the provisional organization of the thrombus, 
and supposes that the disintegration of the clot is immediately fol- 
lowed by the adhesion of the walls of the vessel, to which I have 
called attention as the definite termination of the whole process. 6 

As I have already stated, peculiarly favorable conditions are re* 
quisite for the blood-clot to become organized. It is an absolute law 
in the human organism, that non-vascular tissues, which are nourished 
by means of cells alone, have no great extent ; the articular cartilages, 
the cornea, the tunica intima of these vessels, the tissues, are all in thin 
layers ; in other words, the cells of the human body cannot, like those of 
plants, carry nutrient fluid to any given distance, but are limited in 
their conductive power ; at certain distances new blood-vessels must 
appear, to supply and carry off the nutrient fluid. The blood-clot, 
consisting of cells with coagulated fibrine, is at first a non-vascula* 
cellular tissue, which can only maintain its existence in thin layers. 
This appears from observations, which we shall hereafter often have 
occasion to mention ; namely, that large blood-clots are not organized 
at all, or only in their peripheral layers, while they disintegrate in the 
centre. From this it appears that, in healing by the first intention, a 
small amount of blood lying between the edges of the wound does no 
harm, while a larger amount interferes with healing, or prevents it 
altogether. You will soon be able to verify this observation in the 
clinic. 

The formation and organization of the thrombus have engaged 
the attention of surgeons and anatomists since the time of John 
Hunter and even yet they are not fully understood. We must con- 
sider them here on account of their general histogenetic interest, al- 
though of late it is doubtful whether thrombi are practically as im- 
portant for the results of ligation as was formerly supposed. Even 
Porta called attention to the fact that the quick adhesion and union 
of the tissue around the ligated artery was as important as organiza- 
tion of the thrombus. Surgeons have kept this point well in view, 



CIRCULATION AFTER LIGATION. 



127 



always striving, by most carefully operating and attending to the 
wound, to attain healing by the first intention. But it was the suc- 
cess of acupressure which first showed clearly that the adhesion of 
the tissues by coagulable exudation even in forty-eight hours is 
enough to keep securely the compressed or twisted artery, even 
when it is the size of the femoral. Although ITocher has shown that, 
even after acupressure, thrombi occur in arteries, yet they are too 
small to check bleeding in a large artery within forty-eight hours. 
Hence, even from this point of view, attempts to replace the ligature 
by other methods, which leave no threads in the wound but permit 
its entire closure by first intention, should be encouraged without 
denying in any way the extraordinary advantages of the ligature. 



Let us now look at the fate of the circulation after ligating a large 
artery in the continuity. Suppose that, for a haemorrhage in the leg, 
the femoral artery has been ligated ; how does the blood now reach 
the leg ? how will the circulation go on ? Just as on closure of capil- 
lary districts, under increased pressure, the blood presses through the 
next permeable vessels, which are thereby dilated ; the same thing 
occurs on closure of small or medium-sized arteries. Under increased 
pressure, the blood flows through the branches close above the 
thrombus, and from the numerous arterial anastomoses, both in the 

Fig. 32. 



Fig. 31. 



Carotid artery of a rabbit, 
injected 6 weeks after 
ligation. After Porto. 



Carotid artery of a goat, injected 
35 months after ligation. Af- 
ter Porta. 



128 



SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 



Fig. 33. 



long axis and various transverse axes of the limb, reaches other arteries, 
through which it soon again streams into the peripheral end of the ligat- 
ed vessel. An arterial collateral circulation is established to the side of 
the ligated and thrombosed portion of the arterial trunk. Without this, 
the part of the body lying below this point would not receive suffi- 
cient blood and would die ; it would dry up or putrefy. Fortunately, 
arterial anastomoses are so free that, even after ligation of a large 
artery, like the axillary or femoral, such a case is not apt to occur ; in 
diseased arteries, however, which do not distend sufficiently, mortifi- 
cation of the affected extremity may occur. The modes in which 
these new vascular connections form vary greatly. Years ago, Porta 
made very profound researches on this point, and from his numerous 
experiments stated the following, as the types of collateral circula- 
tion: 

1. Direct collateral circulation is established; i. e., there are 
strongly-developed vessels, which pass from the central end of the 
artery directly to the peripheral end. 

These uniting vessels are 
chiefly the dilated vasa vasorum, 
and the vessels of the thrombus ; 
it might happen that one of 
these uniting vessels should di- 
late so much as to acquire the 
appearance of being simply the 
trunk regenerated. 

2. There is an indirect col- 
lateral circulation ; i. e., the 
connecting branches of the next 
lateral arteries are greatly di- 
lated, as in the following case, 
Fig. 33. 

The most striking examples 
of both varieties of collateral 
circulation have here been cho- 
sen ; but when you examine the 
numerous sketches of Porta, 
and yourselves repeat these ex- 
periments, you will find that in 
most cases direct and indirect 
collateral circulation are com- 
bined, so the only value of the 
classification is to group the 
different forms in some way. 

It is an excellent anatomi- 




Femoral artery of a large dog, injected 3 months 
after ligation. Att er Porta. 



CIRCULATION AFTER LIGATION. 129 

cal exercise, to represent for yourselves how, after ligation of the 
different arteries of one or both extremities, or of the trunk, the 
blood will reach the parts beyond the point of ligation ; in this you 
would be well assisted by the plates of arterial anastomosis in Krauze's 
text-book of anatomy. In the surgery of old Conrad Martin Lan- 
genbecJc, these conditions are carefully described in the chapter on 
aneurisms. The reversal of the blood-current, which not unfrequently 
takes place in these collateral circulations, occurs with wonderful 
rapidity, when the anastomoses are free ; if, for instance, we ligate the 
common carotid in a man, and then divide the artery beyond the liga- 
ture, the blood escapes with great force from the peripheral end, that 
is, backward as from a vein. In all such cases, where the artery to be 
ligated has free anastomoses, if a piece is to be cut out of the artery, 
we should first ligate both central and peripheral ends, to be insured 
against haemorrhage ; this is an important practical rule, which is 
often neglected. 



CHAPTER II. 
SOME PECULIARITIES OF PUNCTURED WOUNDS. 



LECTURE X 



As a Eule, Punctured Wounds heal quickly by First Intention. — Needle Punctures ; 
Needles remaining in the Body, their Extraction. — Punctured Wounds of the Nerves. 
— Punctured Wounds of the Arteries : Aneurysma Traumaticum, Varicosum, Varix 
Aneurysmaticus. — Punctured Wounds of the Veins, Venesection. 

Most punctured wounds are simple wounds, and usually heal by 
first intention ; many of them are at the same time incised wounds, 
when the puncturing instrument has a certain breadth ; some have 
the characteristics of contused wounds, when the puncturing instru- 
ment was blunt ; in this case there is generally more or less suppura- 
tion. "We make many punctured wounds with our surgical instru- 
ments, as with acupuncture needles — fine, long needles, that we 
occasionally employ to examine whether and how deep below a tumor 
or ulcer the bone is destroyed, etc. ; with acupressure needles, which we 
use for arresting haemorrhage ; with the trocar, a dagger with a three- 
sided point, furnished with a closely-fitting canula, an instrument for 
drawing off fluid from cavities. 

Dirk, sword, knife, and bayonet punctures are often simultaneously 
incised and contused wounds. If these punctured wounds be not 
accompanied by injury of large arteries, veins, or bones, and do not 
enter any of the cavities of the body, they often heal rapidly and 
without treatment. 

The most frequent punctured wounds are those made with needles, 
especially in women, and how rarely a doctor is called for them ! 
Such an injury is only complicated by a needle, or a part of one, en- 
tering the soft parts so deeply that it cannot readily be extracted. 
This occasionally happens in different parts of the body, as from a 
person sitting or falling on a needle, or some such accident. If a 
needle has entered deep under the skin, the symptoms are usually so 



NEEDLE WOUNDS. 131 

slight that the patients rarely have any decided sensation of it ; in- 
deed, they often cannot say whether the needle has really entered, 
and where it is. And in the soft parts this body usually induces no 
external symptoms, but may be carried in the body for months, years, 
or even a lifetime, without trouble, if it do not enter a nerve. The 
needle rarely remains stationary at the point where it entered, but 
wanders about ; it is shoved along to other parts of the body by con- 
traction of the muscles, and thus may come to light a long distance 
from the point of entrance. Cases have been observed where hyster- 
ical women, from the peculiar vanity of attracting the attention of 
physicians, have inserted numerous needles in different parts of the 
body; these needles appeared now here, now there. Even when 
needles have been swallowed, they may without danger pass through 
the walls of the stomach and intestines, and come to the surface at 
any part of the abdominal wall. JB. von LangenbecJc found a pin in 
the centre of a vesical calculus ; on more careful inquiry, it was found 
that, when a child, the patient had swallowed a pin. The pin may 
have passed through the intestine into the bladder ; here triple phos- 
phates were deposited around it in layers, and this was possibly the 
origin of the calculus. Dittle had a similar experience. 

When the needle has remained for a time in the soft parts without 
exciting pain, or when needles, passing through the body from within 
outward, come to the surface close under the skin, they usually excite 
a little suppuration ; the piercing feeling becomes more decided ; we 
make an incision at the painful spot, let out a little thin pus, and in 
the pus-cavity find the needle, which may be readily removed with 
forceps. It is difficult to explain why this body, which for months 
has moved about in the body, should at length excite suppuration 
when it arrives under the skin ; you must here satisfy yourselves with 
a simple knowledge of the facts. The following interesting case may 
render the course of these injuries more clear to you : In Zurich a 
perfectly idiotic female deaf mute, thirty years old, was brought to 
the clinic with the diagnosis : typhus. No history of the case could 
be obtained from the patient or those about her, who were also lack- 
ing in intelligence. The patient, who often remained in bed for days, 
had complained for a short time of pain in the ileo-caecal region, and 
had moderate fever. Examination showed a swelling at this point, 
which increased the following days, and was very painful on pressure ; 
the skin reddened, fluctuation became evident. It was clearly not a 
case of typhus, but you may imagine what different diagnoses there 
were as to the seat of the suppuration, for there was undoubtedly an 
abscess ; it might be inflammation of the ovary, perforation of the 
vermiform process, an abscess in the abdominal walls, etc., etc. ; still. 



132 SOME PECULIARITIES OF PUNCTURED WOUNDS. 

something could be said against all these hypotheses. After a few 
days the reddened skin became very thin, the abscess pointed about 
the height of the anterior superior spinous process of the ilium, a few 
fingers' breadths above Poupart's ligament, and I made an incision 
through the skin ; there was evacuated a gassy, brownish, sanious pus, 
with a strong fecal odor. As I examined the abscess-cavity with my 
finger, I felt a hard, rod-like, firm body in the depth of the abscess, 
and projecting slightly into it. I began to extract it, and pulled and 
pulled till I brought out a knitting-needle almost a foot long, which 
was somewhat rusty and pointed down toward the pelvis. The ab- 
scess-cavity was clothed with flabby granulations. When I tried to 
examine the opening that the needle must have left behind, I could 
no longer find it ; it had closed again, and was covered by the granu- 
lations. The abscess took a long time to heal; it at last did so 
without further accident, so that in four weeks the patient was dis- 
missed. As I showed the unfortunate cretin the extracted needle, she 
laughed in her idiotic way ; that was all we could make out of her ; 
perhaps this may have indicated some slight recollection of the needle. 
It is most probable that the patient had inserted the needle into the 
vagina or rectum — procedures in which even women not idiotic find 
some incredible pleasure, as you may see in Dieffenbach's operative 
surgery in the chapter on extraction of foreign bodies. It is not im- 
possible that in this case the needle passed by the side of the vaginal 
portion of the uterus through the cascum, for, from the gas-containing 
pus of the abscess, we may decide that there was at least a temporary 
communication with the intestine. It is true this cannot be regarded 
as absolutely certain, for pus in the vicinity of the intestines by the 
development of stinking gases may putrefy, even when no communi- 
cation with the interior of the intestines exists or has existed. 

The extraction of recently-entered needles may be very difficult, 
especially as the patients are not unfrequently very undecided in their 
information about the location of the body, and occasionally from 
shame will not acknowledge how the needles (in the bladder, for in- 
stance) obtained entrance. We should, with the left hand, fix the 
spot where we shall most probably find the foreign body, carefully 
endeavoring to press the skin together in folds ; we must at the same 
time be careful that the needle does not again change its position 
while we are making the incision. Sometimes we feel the body more 
or less distinctly, and can cause pain by pressing on it ; these attempts 
must decide the point of our incision. After dividing the skin, we 
attempt to seize the needle with a pair of good dissecting forceps ; 
very tense bands of fascia may readily deceive us, especially about 
the fingers, for with forceps our sense of feeling is always uncertain. 



EXTRACTION OF FOREIGN BODIES. I33 

If we cannot find the needle, we may move the parts some ; the 
needle is then sometimes moved into a position where it may be 
seized more readily. The extraction of foreign bodies requires a cer- 
tain amount of practice and manual dexterity, which we acquire only 
with time and practice ; here natural knack is of great service. 

Punctured wounds, made with instruments not very sharp, are 
occasionally interrupted in their process of healing. Externally they 
heal by first intention, but after a few days there are suppuration and 
inflammation in the deeper parts ; the wound either opens, and the 
whole tract of the wound suppurates, or the pus breaks through at 
some other point. This occurs particularly in cases where a foreign 
body, as the point of a knife, remains behind, or where the wound 
was made with a blunt instrument. In examining the wound, you 
should always bear in mind the possibility of a foreign body remain- 
ing behind, and, if possible, see the instrument with which the injury 
was done, and find exactly in what direction the instrument passed, so 
that you may know about what parts are injured. However, even in 
unfavorable cases there are occasionally very little inflammation and 
suppuration. A short time since a man came to the clinic who, a few 
days previously, had fallen a moderate height from a tree, lighting on 
his left arm, while engaged clipping the small branches. On the dor- 
sal surface, a few inches below the elbow, the arm was swollen ; on 
the volar surface, just above the wrist, there was a slight excoriation ; 
the arm could be extended and flexed without pain ; only pronation 
and supination were impaired and painful. There was no solution of 
continuity of the bones of the forearm ; the bones were certainly not 
broken through. At the swollen spot on the dorsal side, an inch 
below the elbow, immediately under the skin, we could, however, feel 
a firm body, which could be pressed back somewhat, but it at once 
returned to its old position. It felt just as if a piece of bone had 
been broken off lengthwise, and lay close under the skin. Incompre- 
hensible as it must seem for such a detachment of bone to occur by 
simply falling on the arm, without fracture of the radius or ulna, I 
nevertheless had the patient anaesthetized, and again made the at- 
tempt to press into position the suspected fragment ; but it did not 
succeed. As it lay so close under the skin that it would necessarily 
have perforated ere long, I made a small incision through the skin to 
extract it. To our great astonishment, I drew out, not a fragment 
of bone, but a small branch, five inches long, which was quite firmly 
held by the two bones of the forearm. It was incomprehensible how 
this twig could have entered the forearm; but, on more careful 
examination at the above-mentioned excoriated spot on the volar 
surface, we found a linear, slit-like wound, which had already closed, 



134 SOME PECULIARITIES OF PUNCTURED WOUNDS. 

through which the body had apparently passed so quickly that the 
patient had not noticed its entrance. After its extraction the very 
moderate swelling entirely subsided; the small wound discharged 
but little pus, and was entirely closed in eight days. 

These favorable conditions of punctured wounds have given rise 
to the so-called subcutaneous operations, which were introduced into 
surgery more particularly by Stromeyer and Dieffenbach, and consist 
in passing a pointed, narrow knife under the skin, and dividing ten- 
dons, muscles, or nerves, for various purposes of treatment, without 
making any wound in the skin other than the small punctured wound 
through which the tenotome is introduced. Under these circum- 
stances the wound almost always quickly closes by first intention, 
while in open wounds of tendons there is almost always suppuration, 
often extensive death of the tendon. Of this we shall speak further 
in the chapter on deformities (Chapter XVIII.). 

If the puncture has entered one of the cavities of the body, and 
caused injury there, the prognosis will always be doubtful ; there is 
more or less danger, according to the physiological importance and 
vulnerability (the greater or less susceptibility to dangerous inflam- 
mation) of the organ implicated. Such a punctured wound is not so 
dangerous as a gunshot wound. We shall not at present pursue this 
subject further, but must now say something about punctured wounds 
of the nerves and arteries of the extremities. 

Punctured wounds of nerves naturally induce, according to their 
extent, paralysis of variable amount; otherwise they have the same 
effect as incised wounds of the nerves. Regeneration occurs the 
more readily when the whole breadth of the nerve has not been punc- 
tured. The case is different when a foreign body, as the point of a 
needle or a bit of glass, is left in the nerve-trunk ; they may heal in 
here as in other tissues. The cicatrix in the nerve which contains this 
body may remain excessively painful at every touch ; there may also 
be neuralgia or nervous pains extending excentrically. Moreover, 
the severest nervous diseases, acute or chronic, may be induced by 
these foreign bodies. ^Epileptiform spasms, with an aura, a pain in 
the cicatrix preceding the spasm, have been observed after such in- 
juries; some surgeons also assert that traumatic tetanus may also be 
induced by this nervous irritation. This appears to me very doubtful, 
but of this hereafter. The first of these diseases, the so-called reflex 
epilepsy, may usually be cured by the extraction of the foreign body. 

Punctured wounds of arterial trunks or their large branches may 
induce various results. A very small puncture usually closes by the 
elasticity and contractility of the coats ; indeed, there is not always 
a haemorrhage, any more than there is always escape of faeces from 




PUNCTURED WOUNDS OF ARTERIES. 135 

a small puncture of the intestine. If the wound be slit-shaped, the 
bleeding may also be insignificant if the opening gapes but little ; 
but in other cases severe arterial haemorrhage is the immediate result. 
If compression be at once made, and a bandage accurately applied, 
we shall usually succeed not only in arresting the haemorrhage, but 
also in closing the puncture in the artery, just as we should one in the 
soft parts. If the bleeding be not arrested, as already stated, we 
should at once ligate the artery, after enlarging the wound up and 
downward, or at a higher point in the continuity. 

The closure of the arterial wound takes place as follows : A blood- 
clot forms in the more or less gaping wound of the arterial wall ; this 
clot projects slightly into the calibre of the vessel ; but externally it 
is usually somewhat larger, and looks like a mushroom. As described 
in intra-vascular thrombus, this clot is transformed to connective 
tissue ; and thus there is permanent organic closure, without change 
of the calibre of the artery. This 
normal course may be complicated FlG - 34 - 

by layers of new fibrine from the 
circulating blood, depositing on 
the part of the plug projecting 
into the calibre of the vessel, and 

,1 -i • • , 1 i , j. • Artery wounded on the side, with clot, four 

thus closing it by a clot, forming a ftays after the injury; after Porta. 

complete arterial thrombosis; but 

this is rare. Should it happen, we would have the same result as 
after a thrombosis following ligation — development of collateral cir- 
culation, and eventual obliteration of the vessel by organization of 
the thrombus. 

Punctured wounds of the arteries do not always take so favorable 
a course. In many cases, soon after the injury, we notice a tumor at 
the seat of the young cutaneous cicatrix, which gradually enlarges 
and perceptibly pulsates isochronically with the systole of the heart 
and with the arterial pulse. If we place a stethoscope over the 
tumor, we may hear a distinct buzzing and friction sound. If we 
compress the chief artery of the extremity above the tumor, the pul- 
sation and murmur cease and the tumor diminishes somewhat. We 
call such a tumor an aneurism (from avevpyvetv, to dilate), and this 
particular form, arising from wound of an artery, we call aneurisma 
spurium or traumaticum, in contradistinction to the aneurisma 
verum, arising spontaneously from other diseases of the artery. 

Whence comes this tumor, and what is it ? Its origin is as fol- 
lows : The external wound is closed by pressure, the blood can no 
longer flow out of it ; but it forms a way through the opening, which 
is not yet firmly closed by the clot, into the soft parts, and winds 



136 



SOME PECULIARITIES OF PUNCTURED WOUNDS. 



about among them as long as the pressure of the blood is stronger than 
the resistance of the tissues ; a cavity filled with blood is formed in 
immediate communication with the calibre of the artery, part of the 
blood soon coagulates, and there is slight inflammation of the tissue 

about it ; a plastic infiltra- 
Pia « ^ tration, which leads to con- 

nective tissue new forma- 
tion, and this thickened 
tissue forms a sac, into 
and from whose cavity the 
blood flows, while the pe- 
riphery of the cavity is 
filled with layers of clotted 
blood. The buzzing and 
friction that we perceive 
in the tumor arise partly 
from the blood flowing out 
through the narrow open- 
ing in the artery, partly 
by its friction against the 
coagulum, and lastly by 
the regurgitation of the 
blood into the artery. 

Such a traumatic an- 
eurism may also occur in 
another, more secondary 
way ; the arterial wound 
at first heals, and subse- 
quently, after removal of 
the pressure bandage, the 
young cicatrix gives way, 
and then for the first time 
the blood escapes. 
Traumatic aneurisms are not always caused by punctured wounds 
of arteries, but rupture of their coats by great tension and contusions, 
without any external wound, may result in their development. Thus, 
in his surgical lectures, A. Cooper tells of a gentleman who leaped a 
ditch while out shooting, and at the time felt a pain in the hollow of 
his knee, which prevented his walking. An aneurism of the popliteal 
artery soon developed in the bend of the knee, that finally had to be 
operated on. The artery was partly ruptured by the leap. Rupture 
of the tunica intima and muscularis is sufficient to permit the forma- 
tion of an aneurism. Should the tunica adventitia remain uninjured, 




Aneurisma traamaticam of the brachial artery ; after 
Froriep, " Surgical Copperplates." Bd. IV., Plate 483. 



ANEURISM FROM PUNCTURED WOUNDS. 



137 



the blood may detach it from the tunica media ; this forms a variety 
of aneurism called aneurisma dissecans (dissecting aneurism). Cases 
of punctured wounds with subsequent aneurisms occur particularly in 
military practice, but not unfrequently also in civil practice. I saw a 
boy with an aneurism, as large as a hen's-egg, of the femoral artery, 
about the middle of the thigh, that had been caused by puncture with 
a pen-knife, on which the boy fell. A short time since I operated on 
an aneurism of the radial artery, that had developed in a shoemaker 
after an accidental puncture with an awl. 

An aneurism is a tumor communicating directly or indirectly 
with the calibre of an artery. This is the common definition. The 
communication is immediate in the case just described of a simple 
traumatic aneurism. Still, the anatomical conditions of this tumor 
may be more complicated. 

For instance, in a venesection at the bend of the elbow, that is, 
from intentionally puncturing a vein for the purpose of abstracting 
blood, besides the vein, the brachial artery may be wounded ; this is 
one of the most frequent causes of traumatic aneurism, or at least was 
so formerly, when bleeding was more common. In such a case, besides 
the dark, venous blood, we may readily perceive the bright, arterial 
blood ; the whole arm is at once bound up and the artery compressed, 
and in some cases the openings in both vessels heal at once without 
further consequences. But occasionally it happens that this accident 
is followed by an aneurism ; this may have the simple form above de- 
scribed ; but the openings in the two vessels may so grow together that 
part of the arterial blood will flow directly into the vein as into an 
arterial branch, and must then meet the stream of venous blood. This 



Fio. 36. 




Varix aneurismaticus. 



Brachial artery ; after Bell. 
Bd. in., Taf. 263. 



Froriep, "Surgical Copperplates." 



138 SOME PECULIARITIES OF PUNCTURED WOUNDS. 

causes obstruction of the venous current and consequent sacculations, 
dilatations of the calibre of the vein, which we generally term vari' 
ces / in this particular case the varix is called varix aneurismaticus, 
because it communicates with an artery like an aneurism. 

Another case may arise : an aneurism forms between the artery and 
vein, both of which communicate with the aneurismal sac. 

Fio. 37. 




Aneurisma varicosum. a, Brachial artery: b, median vein. The aneurismal sac is cut open ; 
after Dorsey. Froriep, " Surgical Copperplates." Bd. III., Taf. 263. 

We call this aneurisma varicosum. There may also be some 
varieties in the relation of the aneurismal sac, vein, and artery, to each 
other, which, however, are only important as being curious, and change 
neither the symptoms nor treatment, and fortunately have no particular 
names. In all these cases where arterial blood flows directly or indi- 
rectly through an aneurismal sac into the veins, there is distention of 
the veins and a thrill in them, which may be both felt and heard, and 
may even be occasionally perceived in the arteries ; it probably results 
from the meeting of the currents. However, this thrill in the vessels 
is not characteristic of the above state, for it may sometimes be in- 
duced simply by pressure on the veins, and occurs in some diseases of 
the heart. We also occasionally see a weak pulsation in veins dis- 
tended by the above causes, which would even earlier give a correct 
diagnosis. 

Quite recently I saw a number of aneurisms resulting from gun- 
shot-wounds ; in three cases affecting the femoral and external iliac 
arteries, the above-mentioned thrill was very prominent, rendering it 
pretty certain that there was a communication between the artery 
and vein, as was proved by autopsy in one case ; but there were no 
varices in any of these cases ; hence their development is not a neces- 



VENESECTION. 139 

sary result of communication between arteries and veins, or else they 
may in some cases not develop for some years. 

Aneurisms of the arteries, in whatever form they come, if they 
only remained small, would cause no great inconvenience. But in 
most cases the aneurismal sacs grow larger and larger ; functional dis- 
turbances occur in the affected extremity, and finally the aneurism 
may rupture, and a profuse haemorrhage terminate life. In most cases 
the treatment must consist in ligating the aneurismal artery ; but of 
this hereafter. I have considered it practical to explain to you here 
the development of traumatic aneurisms, as in practice they are mostly 
due to punctured wounds ; while in other text-books you will find them 
systematically treated of among diseases of the arteries. We shall 
speak, in a separate chapter, of spontaneous aneurisms and their treat- 
ment. 

Punctured wounds of veins heal just like those of arteries, so that 
I need add nothing here to what was said above ; we need only re- 
mark here that extensive coagulations form more readily in veins than 
in arteries; traumatic venous thrombosis after venesection, for in- 
stance, is far more frequent than traumatic arterial thrombosis after 
punctured wounds of arteries, and, what is far worse, the former variety 
of thrombosis has much more serious results than the latter ; on this 
point you will perhaps hereafter hear more than will be agreeable to 
you. 

We have frequently mentioned venesection, which is a very frequent 
small surgical operation. We shall here briefly review its performance, 
although you comprehend such things quicker and better by once see- 
ing them than I could represent them to you. Should I attempt to tell 
you under what circumstances venesection should be performed, I 
should have to enter deeply into the whole subject of medicine ; quite 
a large book might be written on the indications and contraindications, 
the admissibility, the benefits and injuries of venesection ; hence I pre- 
fer to say nothing on these points as on so many others which you will 
pick up in a few minutes at your daily visits to the clinics, and for 
whose theoretical exposition without special cases we should require 
hours. In regard to the history, we will only mention that, while for- 
merly venesection was performed on any of the subcutaneous veins, 
now it is only done in the veins of the bend of the elbow. If you 
wish to bleed a patient, you first apply a pressure-bandage to the arm, 
to cause obstruction of the peripheral veins ; for this purpose we em- 
ploy a properly-applied handkerchief or the old-fashioned scarlet bleed- 
ing-ribbon, a firm bandage two or three finger-breadths wide with a 
buckle ; when this is firmly applied the veins of the forearm swell up 
and the vena cephalica and basilica with their corresponding median 



140 SOME PECULIARITIES OF PUNCTURED WOUNDS. 

veins appear in the bend of the elbow. You choose, for opening, the 
vein which is most prominent. The arm of the patient is flexed at an 
obtuse angle ; with the left thumb you fix the vein, with the lancet or a 
very pointed straight scalpel in the right hand you puncture the vein 
and slit it up longitudinally two or three lines. The blood escapes in a 
stream ; you allow sufficient to flow, cover the puncture with your 
thumb, remove the bandage from the arm above, and the bleeding will 
cease spontaneously ; the wound should be covered with a small com- 
press and a bandage ; the arm should be kept quiet three or four days, 
then the wound will be healed. Easy as this operation is in most 
cases, it still requires practice. Puncture with the lancet or scalpel is 
to be preferred to the spring-lancet; the latter was formerly very pop- 
ular, but is now very justly going out of fashion ; the spring-lancet is a 
so-called fleam, which is driven into the vein with a spring; we allow 
the instrument to operate, instead of doing it ourselves more certainly 
with the hand. 

Various obstacles may interfere with venesection. In very fat per- 
sons it is often difficult to see or feel the veins through the skin ; then 
besides compression we employ another means, that is holding the 
forearm in warm water, which increases the afflux of blood to this part 
of the body. Moreover, after opening the vein the fat may impede the 
escape of the blood by fat-lobules lying in the opening; these should 
be quickly snipped off with the scissors. Occasionally the flow of 
blood is mechanically obstructed by the arm being rotated or bent at 
a different angle after the puncture has been made, so that the open- 
ing in the vein no longer corresponds to that in the skin ; this is to be 
met by changing the position of the arm. There are other causes for 
the blood not flowing properly; such as the puncture being too small, 
a frequent fault with beginners ; the compression is too weak, this may 
be improved by tightening the bandage ; or, on the contrary, the com- 
pression is too great, so that the artery is also compressed, and little 
or no blood flows from the arm, this may be obviated by loosening the 
venesection bandage. Aids for increasing the flow of blood are : dip- 
ping the hand in warm water, and having the patient rhythmically 
open and close the hand, so that the blood may be forced out by the 
muscular contractions. We shall speak further on this point, as op- 
portunity offers, in the clinic. 



CHAPTER III. 

CONTUSIONS OF THE SOFT PABTS WITHOUT 
WOUJVDS. 



LECTURE XI. 



Causes of Contusions. — Nervous Concussion. — Subcutaneous Eupture of Vessels. — Rup- 
ture of Arteries. — Suggillations. — Ecchymoses. — Eeabsorption. — Termination in 
Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction. — Treatment. 

By the action of a blunt object on the soft parts, the skin will 
sometimes be injured, sometimes it will not ; hence we distinguish con- 
tusions with or without wounds. We shall first consider the latter. 

These contusions are partly caused by the falling or striking of heavy 
objects on the body, partly by the body falling or striking against a 
hard, firm object. The immediate result of such a contusion is a 
crushing of the soft parts, which may be of any grade ; often we per- 
ceive scarcely any change, in other cases the parts are ground to a 
pulp. 

Whether the skin suffers solution of continuity by this application of 
force depends on various circumstances, especially on the form of the con- 
tusing body and the force of the blow, also on the nature of the parts un- 
der the skin ; for instance, the same force would cause contusion without 
a wound in a muscular thigh, that applied to the spine of the tibia would 
cause a wound, for in the latter case the sharp edge of bone would cut 
the skin from within outward. The elasticity and thickness of the 
skin also come into consideration ; these not only vary in different per- 
sons, but may differ in different parts of the body of the same indi- 
vidual. 

In contusion without wound we cannot immediately recognize the 
amount of destruction, but only indirectly from the state of the nerves 
and vessels, and also from the subsequent course. 

In contusion the first symptom in the nerves is pain, just as it is 



142 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 

in wounds, but pain of a duller, more undefined character, although 
it may be very severe. In many cases, especially when he has struck 
against a hard body, the patient has a peculiar vibrating, threatening 
feeling in the injured part ; this feeling, which extends some distance 
beyond the seat of injury, is caused by the concussion of the nerves. 
For instance, if we strike the hand or finger quite hard, only a small part 
is actually contused, but not unfrequently there is concussion of the 
nerves of the whole hand, with great trembling, dull pain, on account of 
which the fingers cannot be moved, and there is almost complete loss of 
feeling for the moment. This condition passes off quickly, usually in a few 
seconds, and then a burning pain is felt in the contused part. The 
only explanation we have of this temporary symptom is that the 
nerve-substance of the axis cylinder suffers molecular displacement 
from the blow, which spontaneously passes off again. These symptoms 
of concussion (the commotion) do not by any means accompany all 
contusions ; they fail especially in cases where a heavy body comes 
against a limb at rest, but they are not unfrequently of great signifi- 
cance in contusions of the head ; here commotio cerebri is not unfre- 
quently united with contusio cerebri, or the former appears alone, for 
instance, in a fall on the feet or buttocks, whence the concussion is prop- 
agated to the brain and may induce very severe accidents or even 
death, without any preceptible anatomical changes. Concussion is es- 
sentially a change in the nervous system, hence we speak chiefly of 
cerebral or spinal concussion. But the peripheral nerves also may be 
concussed with the above symptoms ; but since in such cases the more 
localized contusion is especially prominent, this nervous state is per- 
haps too much neglected. Severe concussion of the thorax may in- 
duce the most dangerous symptoms simply from concussion of the 
cardiac and pulmonary nerves, whereby the circulation and respiration 
are disturbed, although for the most part only temporarily. Nor can 
a reflex action of the concussed nerve, especially of the sympathetic 
on the brain, be entirely denied. Doubtless some of you, when wrestling 
or boxing, have received a blow in the abdomen ; what terrible pain ! 
a feeling of faintness almost overcomes you for a time ; here we have an 
action on the brain and on the heart; one holds his breath and gathers 
his strength, to prevent sinking to the earth. Concussion of the ulnar 
nerve often occurs, when we strike the elbow hard ; most of you proba- 
bly know the heavy, dull pain, extending even to the little finger. 
Compression of sensitive nerves is said to cause contraction of the 
cerebral vessels, as is shown by recent experiments on rabbits ; possi- 
bly this explains the faintness from severe pain. 

All these are symptoms of concussion in the peripheral nerves. 
Now, as we do not know what specially takes place in the nerves, we 



CONTUSIONS OF NERVES AND VESSELS. 143 

cannot judge whether these changes have any effect, and, if so, what, on 
the subsequent course of the contusion, and of the contused wound ; 
hence we cannot here study the nerves any further. Some unim- 
peachable observations seem to prove that this concussion of periph- 
eral nerves may induce motor and sensory paralysis, as well as atrophy 
of the muscles of a limb ; but the connection between cause and effect 
is often difficult to prove. 

Contusions of the nerves are distinguished from concussions by 
the fact that in them certain parts of the nerve-trunks, or their whole 
thickness, is destroyed, to the most varied extent and degree, by the 
force applied, so that we find them more or less pulpy. Under these 
circumstances, there must be a paralysis corresponding to the injury, 
from which we determine the nerve affected, and the extent of the 
effect. On the whole, such contusions of nerves without wounds are 
rare, for the chief nerve-trunks lie deep between the muscles, and so 
are less apt to be injured directly. 

It must a priori be acknowledged that concussion may affect 
other organs and tissues than nerves, and induce temporary or per- 
manent disturbances, not only of the functional but of the nutritive 
processes. Such disturbances may also have an important influence 
on the course of repair after the injury, and are mentioned by some 
surgeons as the chief causes of inflammations that are occasionally 
very violent and develop easily-decomposing exudations and infiltra- 
tions. I am far from denying the influence of an energetic concus- 
sion on a bone whose medulla and vessels are thereby torn, without 
its being fractured ; under some circumstances the results of such an 
injury might be more extensive and tedious than those of a fracture 
from too great bending; but we should not ascribe the frequent 
severity of the course of contused wounds entirely to this cause. 

Contusions of the vessels must be much more apparent, since the 
walls of the smaller vessels, especially of the subcutaneous veins, are 
destroyed by the contusing force, and blood escapes from them. 
Hence, subcutaneous hemorrhage is the almost constant consequence 
of a contusion. It would be much more considerable if in this variety 
of injury the wound of the vessel had sharp edges, and gaped ; but 
this is not usually the case. Contused wounds of the vessel are 
rough, uneven, ragged, and these irregularities form obstacles to the 
escape of the blood ; the friction is so great that the pressure of the 
blood is unable to overcome it ; fibrinous clots form on these inequal- 
ities, even extending into the calibre of the vessel, causing mechanical 
closure of the vessel, or thrombus. Contusion of the wall of a ves- 
sel, with alteration of its structure, may alone cause coagulation of 
the blood ; for Brueke has proved that a living, healthy intima of the 



144 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 

vessel is very important for the fluidity of the blood within the vessel. 
We shall again return to this subject, under contused wounds. The 
counter-pressure of the soft parts prevents an excessive escape of 
blood, for the muscles and skin exercise a natural compression ; hence, 
these subcutaneous haemorrhages, even when from a large vessel of 
the extremities, are very seldom instantly dangerous to life. Of 
course, it is different in hasmorrhages into the cavities of the body ; 
here there is little besides movable parts, that can offer no sufficient 
opposition to the escape of the blood ; hence, these haemorrhages are 
not infrequently fatal. This may be in two ways : partly from the 
amount of blood escaping — into the thorax or abdomen, for instance — 
partly from the pressure of the blood on the parts in the cavity — on 
the brain, for instance — which are not only partly destroyed by the 
blood flowing from large vessels, but are compressed in various direc- 
tions, and their functions thus impaired. Hence, hasmorrhages in the 
brain cause rapidly-occurring paralyses, and often, also, disturbance 
of the sensorium. In the brain we call this escape of blood, as well 
as the symptoms induced by it, apoplexy (from airo and ixXt\go^ to 
knock down). 

If a large artery of an extremity be contused, the conditions are the 
same as in a stitched or compressed punctured wound. A traumatic 
aneurism, a pulsating tumor, forms, as described in the last lecture. 
But this is rare as compared with the numerous contusions occurring 
daily, and is so, doubtless, because the larger arteries lie quite deep, 
and the arterial coats are firm and elastic, so that they tear far less 
readily than the veins, although a short time since, in the clinic, we 
saw a subcutaneous rupture of the anterior tibial artery. A strong, 
muscular man had a fracture of the leg; the skin was uninjured; the 
tibia was fractured about the middle, the fibula rather higher. The 
considerable tumor that at once formed at the seat of fracture pulsated 
visibly and perceptibly to the touch on the anterior surface of the leg. 
There was very evident buzzing sound in it, which I was able to de- 
monstrate to the class. The foot was dressed with splints and band- 
ages ; we avoided the application of an immovable dressing, so that 
we might watch the further course of the traumatic aneurism that had 
evidently formed here. We renewed the dressing every three or four 
days, and could see the tumor gradually becoming smaller and pulsat- 
ing less strongly, till it finally disappeared, a fortnight after the injury. 
The aneurism had been cured by the compression from the bandage. 
Nor was the recovery of the fracture interrupted ; eight weeks after 
the injury, the patient had full use of his limb. 

The most frequent subcutaneous haemorrhages in contusions are 
from rupture of the subcutaneous veins. These effusions of blood 



CONTUSIONS OF BLOOD-VESSELS. 145 

cause visible symptoms which vary, partly from the quantity of the 
effused blood, partly from the distribution of the blood in the tissue. 

The more vascular a part, and the more severely contused, the 
greater the extravasation. The extravasated blood, if it escapes from 
the vessels slowly, forms a passage-way between the connective-tissue 
bundles, especially those of the subcutaneous connective tissue and 
muscles ; this must cause infiltration of the tissue with blood and con- 
sequent swelling. These diffuse and subcutaneous haemorrhages we 
term suggillations or suffusions. The more relaxed and yielding, and 
the easier to press apart the tissue is, the more extensive will be the 
infiltration of blood, if it flows gradually but continually from the 
vessels for a time. Hence, as a rule, we find the effusions of blood in 
the eyelids and scrotum quite extensive, because the subcutaneous 
connective tissue there is so loose. The thinner the skin, the more 
readily and quickly we shall recognize the suggillation ; the blood has 
a blue color through the skin, or presses into it and gives it a steel- 
blue color. Under the conjunctiva bulbi, on the contrary, the blood 
appears quite red, as this membrane is so thin and transparent. 
Blood extravasations in the cutis itself appear as red spots (purpura) 
or striae (vibices) ; but in this form they are very rarely due to contu- 
sion, they are caused by spontaneous rupture of the vessels ; whether 
because the walls of the vessels are particularly thin in some persons, 
as in those already mentioned as being of hemorrhagic diathesis, or 
because they are especially brittle and tender from some unknown 
condition of the blood, as in scorbutis, some forms of typhus, morbus 
maculosus Werlhofii, etc. Contusion of the cutis may usually be rec- 
ognized by a very dark-blue color, passing into brown ; also by stria- 
tion of the epidermis with so-called chaps, or, as they are technically 
termed, excoriations, flaying of the skin. 

If much blood escape suddenly from the vessels and be effused in 
the loose cellular tissue, a more or less bounded cavity is formed. 
This form of effusion of blood is called ecckymosis, ecchymoma, hm- 
matoma, or blood-tumor. Whether the skin be discolored- at the 
same time, depends on how deep the blood lies under it. In deep 
effusions of blood, diffuse as well as circumscribed, we often find no 
discoloration of the skin, especially soon after the injury ; we only 
perceive a tumor whose rapid development immediately after an injury 
at once shows its nature ; this tumor feels soft and tense. The cir- 
cumscribed effusion of blood offers the very characteristic feeling of 
fluctuation. You may most readily obtain a clear idea of this feeling 
by filling a bladder with water and then feeling its walls. In surgical 
practice the recognition of fluctuation is very important, for there are 
innumerable cases where it is important to determine whether we 
10 



146 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 

* 

have to deal with a tumor of firm consistence, or with one containing 

fluid. You will be shown in the clinic how it is best to make this 
examination in different cases. 

Some of these effusions of blood have received particular names 
according to the localities where they occur. Thus those coming on 
the heads of the newly-born, between the various coverings of the 
skull and in it, are called cephalhematoma (from Ke<f>aXrj, head, and 
aLfiaroo), to soil with blood), cephalic tumors of the newly-born. The 
extravasations in the labia majora, from contusions or the spontaneous 
rupture of distended veins, have received the neat name of episiohmma- 
toma or episiorrhagia (from eireiatov, the external genitals). Effu- 
sions of blood in the pleura and pericardium have also special desig- 
nations : hmmatothorax, hcematopericardium, etc. On the whole, 
we attach little importance to these euphonic Latin and Greek names ; 
but you should know them, so as to understand them when reading 
medical books, and not seek for any thing mysterious behind them ; 
also that you may use them so as to express yourself quicker, and be 
readily understood. 

The subsequent course and symptoms are very characteristic of 
these subcutaneous effusions of blood. Looking first at the diffuse 
effusions of blood, immediately after the injury, we are rarely able, to 
decide how extensive the bleeding has been or still is. If you ex- 
amine the contused part the second or third day after the injury, you 
notice that the discoloration is more extensive than on the first day ; 
this appears to increase subsequently ; that is, it becomes more per- 
ceptible. The extent is sometimes astonishing. We once had in the 
clinic a man with fractured scapula ; at first there was only slight dis- 
coloration of the skin, although there was a large fluctuating tumor. 
On the eighth day, the whole back from the neck to the gluteal mus- 
cles was of a dark steel-blue, and presented a peculiar, almost comical 
appearance, the skin looking as if painted. Such widely-spreading 
extravasations are particularly apt to occur in cases of fractured bones, 
especially of the arm or leg. But fortunately this partly dark-blue, 
partly bluish-red color, along with which the skin is not sensitive and 
scarcely swollen, does not remain so, but further changes take place ; 
first there is further change of color, the blue and red pass into mixed 
brown, then to green, and finally to a bright lemon yellow. This pecu- 
liar play of colors has given rise to the expression of " beating one 
black and blue," or " giving one a black eye." The last color, the 
yellow, usually remains a long time, often for months ; it finally dis- 
appears, and no visible trace of the extravasation remains. 

If we ask ourselves whence come these various colorings of the 
skin, and if we have the opportunity of examining blood extravasa- 



CONTUSIONS OF BLOOD-VESSELS. 147 

tions in various stages, we find that it is the coloring matter of the 
blood which gradually passes through the metamorphoses and shades 
of color. When the blood has escaped from the vessels and entered 
the connective tissue, the fibrine coagulates. The serum enters the 
connective tissue, and thence passes back into the vessels ; it is re- 
absorbed. The coloring matter of the blood leaves the blood-corpus- 
cles, and in a state of solution is distributed through the tissue. The 
fibrine and blood-corpuscles, for the most part, disintegrate to fine 
molecules, and in this state are reabsorbed by the vessels ; as in the 
thrombus a few white blood-cells may attain a higher development. The 
coloring matter of the blood which saturates the tissues passes through 
various, not thoroughly understood metamorphoses with change of 
color, till it is finally transformed into a permanent coloring matter, 
which is no longer soluble in the fluids of the body — hcematoidi?i. 
As in the thrombus, this is partly granular, partly crystalline ; in a 

pure state it is orange-colored, and 
Fig. 38. if scanty gives the tissue a yellow- 

ish color, if plentiful a deep orange 
hue. 

JReab.sorption of the extravasa- 
tion almost always takes place in 
diffuse suggillations, as the blood 
is very widely distributed through 
the tissues, and the vessels that 
have to accomplish the reabsorp- 
tion have not been affected by the 
0r o°an'S , £&3$S&%£ a £& contusion ; it is the most desirable 
fied400, and under favorable circumstances 

the most frequent result after sub- 
cutaneous and intermuscular effusions of blood. 

The case is different in circumscribed effusions, in ecchymoses. 
Here the first question is as to the extent of the effusion, then about 
the state of the vessels surrounding it ; the more developed the latter, 
the less they have been injured by the contusion, the more hope there 
is of early reabsorption ; but its occurrence is always less constant in 
large effusions of this variety. There are various factors which inter- 
fere with it ; in the first place, there is thickening of the connective 
tissue around the effusion of blood, as around a foreign body (as in 
traumatic aneurism also), by which the blood is entirely encapsulated ; 
the fibrine of the effusion is deposited in layers on the inner surface 
of this sac, the fluid blood remains in the middle. Thus the vessels 
about the blood-tumor can take up very little fluid, as they are sepa- 
rated from the fluid part of the blood by layers of fibrine, which are 




148 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 

often quite thick. Here we have the same conditions as in large 
fibrinous exudations in the pleura ; there also the fibrous deposits on 
the walls greatly interfere with reabsorption. This can only take 
place perfectly when the fibrine disintegrates to molecules, becomes 
fluid, and thus absorbable ; or when it is organized to connective tis- 
sue, and supplied with blood and lymph vessels. This is not so very rare 
in pleuritic deposits. But there is also another fate for such extrava- 
sations. The fluid portion of the blood may be completely reabsorbed, 
and a firm tumor composed of concentric, onion-like layers may remain. 
This results occasionally from extravasations in the labia majora; a so- 
called fibrous tumor is thus formed ; in the cavity of the uterus, also, 
such fibrous tumors occasionally develop. Some hcematomata may be 
partly organized to connective tissue, and gradually take up lime-salts 
and entirely calcify ; a rare termination, but one that occurs in effu- 
sions of blood in large goitres. Another mode is the transformation 
of the blood-tumor to a cyst ; this is seen in the brain, and in soft 
tumors. Besides other modes of origin, some cysts in goitres may owe 
their origin to such effusions. By a cyst or encysted tumor we mean 
sacs or bags containing more or less fluid. The contents of these 
cysts, resulting from extravasation of blood, are darker or lighter ac- 
cording to their age ; indeed, the blood-red may totally disappear 
from them, and the contents become quite clear or only slightly 
clouded by fat molecules. In large circumscribed extravasations you 
will find numerous and beautifully-formed hematoidin crystals more 
rarely than in small diffuse ones, for in the former fatty disintegration 
of the elements of the blood predominates, hence excretion of choles- 
terine crystals is more common in them. The capsule enclosing these 
old effusions arises partly from organization of the peripheral parts 
of the blood-clot, partly from the circumjacent tissue. 

Suppuration of circumscribed extravasations is far more frequent 
than the two last described metamorphoses, but is not so common as 
reabsorption. The inflammation in the vicinity, and the plastic pro- 
cess in the peripheral part of the extravasation, from which, in the 
two preceding cases, the thickened connective tissue was developed, 
which encapsulated the blood, assume a more acute character in the 
case we are about to speak of; a boundary layer is formed here also, 
but not slowly and gradually as in the preceding cases, but by rapid 
cell-formation ; plastic infiltration of the tissue does not lead to devel- 
opment of connective tissue, but to suppuration ; the inflammation 
after a time attacks the cutis, and it suppurates from within outward, 
and is finally perforated, and the pus mixed with blood is evacuated ; 
the walls of the cavity come together, cicatrize and grow together, 
and healing thus takes place. We shall speak more exactlv of this 



CONTUSIONS OF BLOOD-VESSELS. 149 

mode of healing when treating of abscess; we call any pus-tumor, 
i. e., circumscribed collection of pus under the skin at any depth, an 
abscess : hence we term the above process the conversion of an ex- 
travasation of blood into an abscess. This process may be very pro- 
tracted, it may last three or four weeks, but, if not dangerous from its 
location, it generally runs a favorable course. We recognize the sup- 
puration of an extravasation of blood by the increasing inflammatory 
redness of the skin, the growth of the tumor, increasing pain, occasion- 
ally accompanied by fever, and finally by thinning of the skin at some 
point, where it is finally perforated. 

Lastly, there may be rapid decomposition of the extravasation ; 
fortunately, this is rare. Then the tumor grows hot, tense, and very 
painful, the fever usually becomes considerable, chills and other severe 
general symptoms may occur. This termination is the worst, and the 
only one that requires speedy relief. 

Whether there shall be reabsorption, suppuration, or putrefaction 
of an extravasation, depends not only on the amount of the effused 
blood, but very much on the grade of the contusion that the tissues 
have suffered ; as long as these may return to their normal state, re- 
absorption will be probable ; if the tissues be broken down and pass 
into disintegration or decomposition, they will induce suppuration 01 
decomposition of the blood ; briefly, the effused blood will have the 
same fate as the contused tissue. 

While the skin is uninjured we cannot judge accurately how much 
the muscles, tendons, and fasciae, are injured ; occasionally the size of 
the extravasation may give some aid on this point, but it is a very 
uncertain measure ; it is better to test the amount of functional ac- 
tivity of the affected muscles, but even the results thus given must be 
carefully accepted ; the amount of force that has acted on the part 
may lead to an approximate estimation of the existing subcutaneous 
destruction. In contusion of muscles, as in wounds, healing takes 
place from the crushed muscular elements undergoing molecular disin- 
tegration and being absorbed, or by being eliminated with the pus on 
suppuration of the extravasation, but then there is new formation both 
of connective tissue and muscle. 

The largest extravasations, either diffuse or circumscribed, are 
usually accompanied by injuries of the bones ; but it will be better to 
consider the injury of the bone in a separate section. 

If a portion of the body be so crushed as to be entirely or mostly 
incapable of living, it becomes cold, bluish red, brownish red, then 
black ; it begins to putrefy ; the products of putrefaction enter the 
neighboring tissues and the blood ; the local inflammations, as well as 
the fever, assume peculiar forms. As this is the same in contusions 
with or without wounds, we shall speak of it later. 



150 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 

The treatment of contusions without wound has for its object the 
conduction of the process to the most favorable termination possible, 
that is, to reabsorption of the extravasation ; when this takes place, 
the injuries to the other soft parts also progress favorably, as the whole 
process remains subcutaneous. We here refer solely to those cases 
where the contusion of the soft parts and the extravasation are the 
only objects of treatment; where the bone is broken it should be 
treated first of all, the extravasation of itself would scarcely be an ob- 
ject for special treatment. If called to a contusion that has just oc- 
curred, the indication may be to arrest any still continuing haemor- 
rhage ; this is best done by compression, which, where convenient, is to 
be made by evenly-applied bandages. In North Germany, when a 
child falls on its head, or knocks its forehead, the mother or nurse at 
once presses the handle of a spoon on the injured spot to prevent the 
formation of a blood-bruise. This is a very suitable popular remedy ; 
by the instantaneous compression the further escape of blood is hin- 
dered, as is also its collection at one point, because it is compelled by 
the pressure to distribute itself in the surrounding tissue ; an ecchy- 
mosis just forming may thus be transformed into a suggillation, so that 
the blood may more readily be absorbed. You may occasionally at- 
tain the same object by a well-applied bandage. 

But we rarely see the injury so early, and in the great majority 
of cases there is also an injury of a bone or joint, and the treatment 
of the blood-extravasation is a secondary object. 

The use of cold, in the shape of bladders or rubber bags filled with 
ice, or of cold lotions, to which it is an old custom to add vinegar or 
lead-water, is resorted to as a remedy in recent contusions; it is 
said to prevent excessive inflammation. But you must not rely too 
much on these remedies ; the means that most aids the reabsorption 
of blood extravasations is regular compression and rest of the part. 
Hence it is best to envelop the extremities in moist bandages, and 
over them apply wet cloths, which are to be renewed every three or 
four hours. Other remedies, which usually act well in inflammations 
of the skin, such as mercurial ointment, are of little use here. But I 
must not forget arnica ; this remedy is so honored by some families 
and physicians that they would consider it unpardonable to neglect 
prescribing lotions of infusion of arnica, or of water with the addition 
of tincture of arnica. Faith is mighty; one believes in arnica, an- 
other in lead- water, a third in vinegar, as the potent external reab- 
sorbent. In all cases the effect is doubtless simply due to the moist- 
ure and the variation of temperature of the skin caused by the com- 
press, whereby the capillaries are kept active, now brought to contrac- 
tion, now to dilatation, and thus placed in a better state for reabsorp- 
tion because thev are active. 



TREATMENT OF BLOOD-EXTRAVASATIONS. 151 

Diffuse blood-extravasations of the skin with moderate contusion 
of the soft parts are usually absorbed without much treatment. If a 
circumscribed extravasation does not change considerably in the course 
of a fortnight, there is nevertheless no indication for further interfer- 
ence. We then paint the swelling once or twice daily with dilute 
tincture of iodine, compress it with a suitable bandage, and not unfre- 
quently see the swelling gradually subside after several weeks. 
Should it become hot, and the skin over it grow red and painful, we 
must expect suppuration ; then even the continued application of cold 
will rarely change the course, though it may alleviate it. Then, in 
order to hasten the termination of the suppuration, which cannot be 
avoided, we may apply warm fomentations, either simply of folded 
muslin wet with warm water or cataplasms ; now you quietly await 
the further course ; if the general health be not impaired, but the pa- 
tient feels pretty well, you calmly await perforation ; it will perhaps 
be weeks before the skin gradually becomes thinner at some point 
and finally opens, the pus is evacuated, the walls of the large cavity 
fall together, and in a short time the parts are all healed. At the 
commencement of this lecture I mentioned a case where, with a frac- 
tured scapula, there was an enormous partly diffuse, partly circum- 
scribed extravasation ; here there was a strongly-fluctuating tumor, 
which was not reabsorbed, while the diffuse effusion was rapidly re- 
moved ; the suppuration did not end in perforation till the fifth week, 
then one and a half to two quarts of pus were evacuated ; a week 
later this enormous cavity was healed, and the patient left the hospi- 
tal well. Why we do not here interfere earlier and aid Nature by an 
incision, we shall consider more closely when we treat of abscesses. * 

Should the tension of the swelling rapidly increase, however, dur- 
ing the suppuration of the extravasation, and high fever with chills 
occur, we may suppose that the blood and pus are decomposing, that 
there is putrefaction of the enclosed fluid. Fortunately, this is rare, 
and occurs almost exclusively where there is great crushing of the 
muscles or splintering of the bone. With such symptoms of course 
the putrid fluid should be quickly evacuated ; then you should make 
a large incision through the skin, unless this be forbidden by the ana- 
tomical position of the parts ; in which case several small incisions 
should be made at points where the fluid may escape freely and easily. 
These incisions greatly alter the aspect of the case ; you have changed 
the subcutaneous contusion to an open contused wound. Now other 
conditions come into play, which we shall treat of in the next lecture. 
We must still mention that, if extensive putrefaction of the soft parts 
follows such contusions, amputation is indicated, although this unfortu- 
nate case rarely happens without coincident fracture of the bones. 



CHAPTER IV. 

CONTUSED AND LACERATED WOUNDS OF THE 
SOFT PARTS. 



LECTURE XII. 

Mode of Occurrence of these Wounds ; their Appearance. — Slight Haemorrhage in Con- 
tused Wounds. — Early Secondary Haemorrhages. — Gangrene of the Edges of the 
Wound. — Influences that effect the Slower or more Eapid Detachment of the Dead 
Tissue. — Indications for Primary Amputation. — Local Complications in Contused 
Wounds ; Decomposition, Putrefaction, Septic Inflammations. — Contusion of Ar- 
teries ; Late Secondary Haemorrhages. 

The causes of contused wounds, of which we have to treat to-day, 
are the same as those of simple contusions, only in the first cases the 
force is usually greater than in the latter, or the body by which they 
are induced is of such a form as to divide the skin and soft parts 
easily, or else parts of the body have been injured where the skin is 
particularly thin, or lies over parts unusually firm. 

The kick of a horse, blow from a stick, bite of an animal or a man, 
being run over, wounding with blunt knives, saws, etc., are frequent 
causes of contused wounds. Nothing, however, causes more contused 
wounds than rapidly-moving wheels and rollers of machinery, cutting- 
machines, circular-saws, spinning-jennies, and the various machines 
with cog-wheels and hooks. All of these instruments, the product 
of advancing industry, do much injury among the operatives. Men 
and women, adults and children, with crushed fingers, mashed hands, 
ragged, lacerated wounds of the forearm and arm, are now among the 
constant patients in the surgical wards of hospitals in every large 
city. Innumerable persons are thus maimed of fingers, hands, or 
arms, and many of these patients die as a result of their injuries. If 
to these you add (what recently is becoming rarer, it is true) railroad 
injuries, those caused by blasting, building tunnels, etc., you may 



APPEARANCE OF CONTUSED WOUNDS. 153 

imagine, not only how much sweat, but how much blood, clings to the 
many evidences of modern culture. At the same time it is not to be 
denied that the chief cause of these accidents is the carelessness, 
often the foolhardiness, of the workman. Familiarity with the dan- 
gerous object renders persons at last careless and rash ; some pay for 
this with their lives. 

Gunshot wounds also essentially belong to contused wounds ; but, 
as they have some peculiarities of their own, we shall treat of them 
in a special chapter. Lacerated wounds, and tearing out of pieces 
from the limbs, we shall consider at the end of this chapter. 

Fractures of bones of the most varied and dangerous varieties ac- 
company contused wounds from all the above causes ; but for the 
present we shall leave these out of consideration, and treat only of the 
soft parts. 

In most cases, the appearance of a wound indicates whether it was 
due to incision or contusion. You already know the character of in- 
cised wounds, and I have alluded to some cases where a contused 
wound had the appearance of an incised one, and the reverse. Con- 
tused wounds, like incised, may be accompanied by loss of substance, 
or there may be simply solution of continuity. The borders of these 
wounds are generally uneven, especially the edges of the skin ; the 
muscles occasionally look as if chopped ; tags of the soft parts, of 
various sizes, not unfrequently large flaps, hang in the wound, and 
may have a bluish-red color, from the blood stagnated or effused in 
them. Tendons are torn or pulled out, fasciae are torn, the skin, for 
some distance around the wound, is not unfrequently detached from 
the fascia, especially if the contusing force was combined with a tear- 
ing and twisting. The grade of this destruction of the soft parts of 
course varies greatly, and its extent cannot always be accurately de- 
termined, as we cannot always see how far the contusion and tearing 
extend beyond the wound ; from the subsequent course of the wound 
we often satisfy ourselves that the contusion extended much further 
than the size of the wound indicated ; that separation of muscles, di- 
visions of fasciae, and effusions of blood, extended under the skin, 
which may have been but little torn. It is unfortunate that the skin- 
wound gives no means of judging of the extent and depth of the con- 
tusion, for it renders it very difficult to correctly estimate such an in- 
jury at the first examination; while the appearance of the wound 
gives the laity no idea of danger, the experienced surgeon soon sees 
the gravity of the case. 

Since the injury, especially when due to machinery, is very rapidly 
done, the pain is not great ; and immediately after the injury the pain 
from contused wounds is often very slight ; the more so, the greater 



154 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

the injury and crushing of the parts. This is readily explained by 
the nerves in the wound being entirely mashed and destroyed, conse- 
quently incapable of conducting ; moreover, what I told you in the 
last lecture about local concussion of nerves, the so-called stupor of 
the injured part, comes into play. 

At first sight it seems rather remarkable that these contused 
wounds bleed little, if any, even if large veins or arteries be crushed 
or torn. There are well-observed cases to show that, after complete 
crushing of the femoral or axillary artery, there was absolutely no 
primary haemorrhage. It is true, this is rare ; in many cases where there 
is complete solution of continuity of a large artery by a contusion, 
although there is no spirting stream, there is constant trickling of 
blood ; this, coming from the femoral artery, would speedily cause 
death. I have already told you how this arrest of haemorrhage takes 
place in small arteries, but will make it clearer to you by an illustra- 
tion. A railroad hand was run over by a locomotive, so that the 
wheel passed over his left thigh just below the hip-joint. The unfor- 
tunate was at once brought on a litter to the hospital ; meantime he 
had lost much blood, and came in very pale and anaemic, but perfectly 
conscious. After complete removal of the torn clothing, we found a 
horrible mangling of the skin and muscles. The bone was crushed to 
atoms, the muscles were partly mashed to pulp, partly hung in tags 
from the wound, the skin was torn up as far as the hip-joint. At no 
point of this horrible wound did an artery spirt, but from the depth con- 
siderable blood constantly trickled out, and the general state of the pa- 
tient clearly showed that he had already lost much blood. It was evident 
that the only thing to be done here was to amputate at the hip-joint, 
but in the condition the patient then was, this was not to be thought 
of; the new loss of blood from this severe operation would undoubt- 
edly have been at once fatal. Hence it was, first of all, necessary to 
arrest the haemorrhage, which evidently came from a rupture of the 
femoral artery. I first tried to find the femoral in the wound, while it 
was compressed above ; but all the muscles were so displaced, all the 
anatomical relations were so changed, that this was not quickly done, 
hence I proceeded to ligate the artery below Poupart's ligament. 
After this was done, most of the bleeding ceased, but not entirely, on 
account of the free arterial anastomosis ; and as no regular dressing 
could be applied, on account of the existing mangling, I surrounded 
the limb firmly with a tourniquet, close below where I proposed 
to exarticulate. Now the bleeding stopped; we gave various 
remedies to revivify the patient ; wine, warm drinks, etc., were ad- 
ministered, so that, toward evening, he had so far recovered that his 
temperature was again normal, and the radial pulse was again good. 



HEMORRHAGE FROM CONTUSED WOUNDS. 155 

I should have preferred postponing the operation till the following 
day, if, in spite of ligature and tourniquet, with the strengthening of 
the heart's beat, there had not been some bleeding from the wound, so 
that I feared the patient might bleed to death during the night. 
Hence, with the able help of my assistants, I exarticulated the thigh 
as rapidly as possible. During the operation the absolute loss of 
blood was not great, but it was too much for the already-debilitated 
patient. At first all seemed to go well ; the spirting vessels were all 
ligated, the wound cleansed, and the patient placed in bed ; soon he 
suffered from restlessness and dyspnoea, which increased, finally con- 
vulsions occurred, and the patient expired two hours after the opera- 
tion. Examination of the femoral artery of the crushed extremity 
showed the following : In the upper third of the thigh there was a 
crushed and torn part, comprising about one-third the calibre of the 
artery. The tags of the tunica intima, as well as the other coats of 
vessel, and the connective tissue of the sheath, had rolled up into the 
calibre of the artery, and the blood could only escape slowly ; the 
surrounding tissue was completely saturated with blood. In this case, 
no clot had formed in the artery, as the escape of blood was still too 
free to permit this ; but, if you imagine that the contusion had affected 
the entire circumference of the artery, you may understand how the 
tags of the coats of the vessel pressing into its calibre from all sides 
might have rendered the escape of the blood more difficult, or even 
impossible ; then a thrombus would have formed, and stopped the 
vessel, and gradually have become organized, so as to cause permanent 
closure, just as after ligation. If no haemorrhage had followed the partial 
crushing of the artery in this case, if, for instance, the crushing had 
occurred without an external wound, possibly a clot would simply have 
formed at the part roughened by the contusion, a thrombus forming 
from the wall ; in this case there might have been crushing of the 
artery with preservation of its calibre, a result that is said to have 
been observed. 

If you apply the above-described condition of a large crushed ar- 
tery to smaller arteries, you will understand how there may here more 
readily be complete spontaneous plugging of the calibre of the vessels 
partly by in-rolling of the fragile, torn tunica intima, partly by con* 
traction of the tunica muscularis and by the tags of the adventitia, 
and that consequently bleeding may fail almost entirely in such con- 
tused wounds. 

Observation of this led a French surgeon, Chassaignac, to invent 
an instrument for crushing off portions of the body ; he terms this 
operation ecrasement, the instrument he calls an 'ecraseur. It con- 
sists of a strong metallic ligature, composed of small links, which 



156 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

is to be applied around the part to be removed, and then drawn slow- 
ly into a strong metal frame by means of a ratch arrangement. 
When the instrument is properly used it causes absolutely no haemor- 
rhage. Little favor as the instrument at first found among surgeons, 
from their dislike to contused wounds in operative surgery, there is 
no doubt of its advantages in suitable cases. Wounds caused by 
ecrasement usually heal with very little local or general reaction ; co- 
incident inflammations occur less frequently with this class of wounds 
than with pure incised wounds. Nevertheless ecrasement will always 
be limited to a small number of operations. 

There is another factor for limiting the haemorrhages in extensive 
contusions, that is, the weakening of the heart's action caused by the 
injury, probably due to reflex action. Persons badly injured, besides 
suffering from loss of blood and injury of the nerve-centres, are usually 
for a time in a state of numbness or stupor ; the word most commonly 
used to express this state of depression is " shock." The fright from 
the injury and all thoughts about it, which follow in rapid succession, 
unite in producing great psychical depression, which has a paralyzing 
effect on the heart's action. Still, even in persons not greatly af- 
fected psychically by the injury, as old soldiers who have often been 
wounded, or very phlegmatic persons, a severe injury is not entirely 
without this effect, so that we must suppose that there are purely 
physical causes for shock. Contusions of the abdomen have an even 
more depressing effect on the nerve-centres than do those of the ex- 
tremities, as I have already told you. In this connection the so-called 
beating-experiment (Klopfversuch) of Goh is very interesting: if we 
repeatedly strike a frog sharply on the belly with the handle of a 
scalpel, he becomes as it were paralytic ; as a result of paresis of their 
walls, the abdominal vessels distend greatly and take up almost all the 
blood, so that all the other vessels and even the heart become blood- 
less, and the latter only contracts feebly. 

When the patient has recovered from this state of psychical and 
physical depression, the heart begins to act with its former or even 
greater energj', then haemorrhages may occur from vessels that had not 
previously bled. This variety of secondary haemorrhage occurs after 
operations, when the effect of the anaesthetic has passed off. Hence 
the patient should be carefully watched at this time, to guard against 
such secondary haemorrhages, especially if, from the locality of the in- 
jury, there be reason to suspect that a large artery has been injured. 

Now we must again examine somewhat more attentively the local 
changes in the wound. 

Although doubtless the processes that take place in the contused 
wound, the changes on its surface and final healing, must be essentially 
the same as in incised wounds, still in the appearances in the two cases 



HEALING OF CONTUSED WOUNDS. 157 

there are considerable differences. One very important circumstance 
is, that in contused wounds the nutrition of the edges of the skin and 
soft parts is more or less extensively destroyed or impaired, or, to ex- 
press this more anatomically, the circulation and nerve influence in the 
borders of contused wounds are more or less lost. This at once pre- 
vents the possibility of healing by first intention, as this requires per- 
fect vitality in the surfaces of the wound. Hence contused wounds 
always heal with suppuration. 

This observation causes us to introduce sutures or try firm union by 
plasters very rarely ; you may consider this as a general rule. There 
are exceptions to this rule, which you will only learn exactly in the 
clinic, and of which I shall only incidentally remark, that occasionally 
we fasten large, loose flaps of skin in their original position, not be- 
cause we expect them to unite by first intention, but that they may 
not from the first retract ±00 much and atrophy to too great an ex- 
tent. 

Granulation and suppuration are esentially the same as in wounds 
with loss of substance, except that they are slower, and we might say 
more uncertain at many places. In incised wounds with loss of sub- 
stance also a thin superficial layer of tissue is occasionally lost, if it 
be not very well nourished ; but this is insignificant as compared with 
the extensive loss of tissue-shreds that occurs in contused wounds. 
Many days, often for weeks, tags of dead (necrosed) skin, fascia, and 
tendons, hang to the edges of the wounds, while other parts are 
luxuriantly granulating. 

This process of detachment of the dead from the living tissue 
takes place as follows : A cell infiltration and formation of vessels, lead- 
ing to development of granulations, start from the borders of the 
new tissue ; granulations form on the border of the healthy tissue, and 
their surface breaks down into pus. With this change to the fluid state 
as it were the solution and melting of the tissue, of course the cohe- 
sion of the parts must cease, and the dead shreds, which previously 
were in continuity with the living tissue by their filamentary connec- 
tion, must now fall. 

Hence part of the surface of contused wounds almost always be- 
comes necrosed (from veitpog, dead), gangrenous (from r\ yayypcuva 
from ypaivo), I consume), which are both expressions for parts in 
which circulation and innervation have ceased, or which are entirely 
dead. The part where the detachment takes place is technically 
called the line of demarcation of the gangrene. These technical 
terms, which refer to every variety of gangrene, no matter how it 
occurs, you must only notice provisionally here. I will try to render 
this process of detachment of necrosed tissue by suppuration more 
distinct by means of a diagram. 



158 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

In the portion of connective tissue represented, suppose c, the 
border of the wound, be so destroyed by the injury that its circulation 
is arrested and it is no longer nourished ; the blood is coagulated in 
the vessels as far as the shading extends in the diagram. Now cell- 
infiltration and inflammatory new formation begin at the outer edge of 
the living tissue, at the border between a and b where the vessels termi- 
nate in loops ; these vascular loops dilate, grow, and multiply ; in the 
tissue the infiltration is constantly increased by wandering cells, as if 
the edge of the wound were here ; granulation tissue is formed ; this 
turns to pus, on the surface, that is, close to the dead tissue, and 
then of course the necrosed part falls, because its cohesion with the 
living tissue has ceased. Hence detachment of the necrosed shreds of 
tissue results from inflammation with suppuration ; when the dead por- 
tion of tissue has fallen, the subjacent, suppurating layer of granula- 
tions comes to light, having been already developed before the 
detachment of the necrosed part. What you here see in connective 
tissue is true of the other tissues, bone not excepted. 




Diagram of the process of detachment of dead connective tissue in contused wounds. Magni- 
fied 300 diameters ; a, crushed necrosed part ; b, living tissue ; c, surface of the wound. 



HEALING OF CONTUSED WOUNDS. 15 g 

In many cases, on the fresh borders of the wound we may see 
about how much will die, but by no means in all cases, and we can 
never decide from the first as to the bordering line of the dead tissue. 

Completely crushed skin usually has a dark-blue violet appearance 
and feels cold; in other cases we at first see no change in it, but in a 
few days it is white, without sensation, later it becomes gray, or, when 
quite dry, grayish or brownish black. These various colors depend 
chiefly on the amount of coagulated blood remaining in the vessels or 
infiltrated in the tissue itself by the partial rupture of the vessels. 
The healthy skin is bordered by a rose-red line which loses itself in a 
diffuse redness ; this is due to collateral dilatation of the capillaries, 
and is partly also a symptom of fluxion, of which we have before 
spoken ; it is the reaction redness about the wound, which we have 
already described ; for the living wound-surface only begins where 
the blood still flows through the capillaries. 

In muscles, fascias, and tendons, we can decide far less frequently, 
and often not at all, from the appearance at first, how far they will be 
detached. 

The time required for the dead tissue to be separated and detached 
from the living varies greatly with the different tissues. This de- 
pends first on the vascularity of the tissues ; the richer a tissue in 
capillaries, the softer it is, the more readily cells spread in it, and the 
richer it is by nature in cells capable of development, so much the 
more rapidly will the formation of granulations and the detachment 
of the necrosed parts come about. All these circumstances combine 
best in the subcutaneous cellular tissue and in the muscles, least so in 
tendons and fascise ; the cutis stands in the middle in this respect. 
The circumstances are the most unfavorable for the bones ; conse- 
quently the separation of the dead from the living takes place most 
slowly. Of this more hereafter. Rich supply of nerves seems to 
have little effect in this process. 

But there are many other influences that hinder the detachment 
of the dead parts, or, what is the same thing, that retard the forma- 
tion of granulations and pus ; such as continued action of cold on the 
wound, as might be effected by applications of bladders of ice. The 
cold keeps the vessels contracted. The cell-movements, the escape of 
cells from the vessels, go on very slowly under the influence of low 
temperature. Treatment by continued warmth, as by the application 
of cataplasms, has the opposite effect ; by this means we increase the 
fluxion to the capillaries and cause them to dilate, as you may readily 
see from the redness you induce on the healthy skin by application of a 
hot cataplasm ; it is known that the high temperature also hastens 
the cell-activity. 






160 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

It is entirely impossible to tell beforehand the influence of the 
general state of the patient on this local process. It is true we may 
say in general terms that it is energetic in the strong, stout, and 
young, more moderate and sluggish in weak persons ; but on this 
point we are often deceived. 

From what has already been said you may suppose that contused 
wounds need much longer to heal than more simple incised ones. It 
will also be evident that there may be circumstances under which 
amputation of the limb will be necessary, all the soft parts being en- 
tirely mashed and torn. There are cases where the soft parts are so 
torn from the bone that this alone remains ; so that on the one hand 
cicatrization cannot occur, and on the other, if the extremity did heal in 
months or years, it would be perfectly useless, and hence it would be 
better to remove it at once. Still, even the simple complete detach- 
ment of the skin from the greater part of an extremity may some- 
times, though rarely, render amputation necessary, as in the case of 
a girl who lost the skin from the wrist to the ends of her fingers be- 
tween the rollers of a spinning machine. 

Fortunately such cases are not frequent; in similar injuries of sin- 
gle fingers we mostly leave the detachment to nature, so that no more 
is lost than is absolutely incapable of living ; for we should always, 
remember in maiming of the hand that every line, more or less, is of 
importance, that especially single fingers, and particularly the thumb, 
should be preserved whenever possible, for such fingers, if only slightly 
capable of performing their functions, are more useful than the best- 
made artificial hand ; for the foot and lower extremity there are 
other considerations, of which we shall hereafter speak when we 
come to complicated fractures of bones. 

Would that this maiming and slow healing, bad as they are, were 
the only cares we had with our patients having contused wounds ! 
Unfortunately there is a whole series of local and general complica- 
tions which directly or indirectly endanger life. We shall first 
speak of the chief local complications ; for the more general, the 
" accidental diseases in wounds," we reserve a future chapter. 

Considerable danger may arise from the decomposing tissue on 
the wound infecting the healthy parts. Putrid matters act as fer- 
ments on other organic combinations, especially on fluids containing 
them; they induce progressive decomposition. We might wonder that 
such extensive decomposition of the part which is injured, if not killed, 
should not occur more frequently than it actually does. But in most 
cases cell-action occurs so quickly on the border of the living tissue 
that a sort of living wall is formed ; this new formation does not read- 
ily permit the passage of putrid matter, and the granulation surface, 



HEALING OF CONTUSED WOUNDS. 161 

if once formed, is particularly resistant to such influences. In many 
places it is a popular remedy to cover ulcers with cow-dung and other 
dirty things; this never causes extensive putrefactions on granulating 
wounds. But if you apply such substances to fresh wounds, and bind 
them firmly on so that the tissue may be mechanically impregnated 
with putrid matter, they will usually become gangrenous to a certain 
depth, and then an energetic cell-formation opposes the putrefaction. 
The reason why decomposing matters act so injuriously on fresh 
wounds, and so slightly on granulating ones, I consider to be, that 
they are chiefly absorbed by the lymphatic vessels. If you inject a 
drachm of putrid fluid into the subcutaneous cellular tissue of a dog, 
the result will be inflammation, fever, and septicaemia. If you make 
a large granulating surface on a dog, and dress it daily with charpie 
soaked in putrid fluid, it will have no decided effect. Certain dis- 
solved putrid matters may pass through the walls of the veins and 
capillaries ; but surgical experience teaches that lymphangitis ac- 
companies poisoned wounds much oftener than phlebitis does. 

The more the tissue is saturated with fluid, the more it is disposed 
to decomposition. Hence, the cases where great cedematous swell- 
ing occurs after contusions are the most dangerous in this respect ; 
but this oedema comes on very readily as the venous circulation is 
obstructed, from extensive rupture and crushing of the vessels, which 
indeed often extend far beyond the borders of the wound. 

Imagine a forearm caught under a stone weighing several hun- 
dred-weight ; there will probably be only a small skin-wound, but 
extensive crushing of the muscles, tendons, and fasciae of the forearm, 
and mashing and rupture of most of the veins ; great cedematous 
swelling will speedily result, as the blood from the arteries is driven 
with greater energy into the capillaries, and cannot escape by its cus- 
tomary passage through the veins, and hence, under the increased 
pressure, the serum escapes through the capillary walls into the tissue 
in greater amount. What a tumult in the circulation and in the 
whole nutrition ! It must soon appear where the blood can still cir- 
culate, and where not. In the wound, at first, under the influence of 
the air, decomposition of the parts incapable of living begins ; this 
advances to the stagnating fluids, and, in unfortunate cases, it con- 
stantly progresses ; the whole extremity swells terribly as far as the 
shoulder ; the skin becomes bright red, tense, painful, covered with 
vesicles, from the escape of serum from the cutaneous capillaries 
under the epidermis. These symptoms usually appear with alarming 
rapidity the third day after the injury. As a result of this disturb- 
ance of circulation, the whole extremity may become gangrenous; 
in other cases, only the fasciae, tendons, and some shreds of skin die. 
11 



162 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

There is cell-infiltration of all the connective tissue of the extremity 
(of the subcutaneous cellular tissue, the perimysium, neurilemma, 
sheaths of the vessels, periosteum, etc.), which leads to suppuration. 
Toward the sixth or eighth day the whole extremity may be entirely 
saturated with pus and putrid fluid. Theoretically, we might imagine 
such cases curable ; that is, we might imagine that, by making suit- 
able openings in the skin, the pus and dead tissue might be evacu- 
ated. But this rarely occurs in practice. If the case has undergone 
the above distention, generally only quick amputation can save the 
patient, and even this is not always successful. We may term this 
variety of infiltration sanio-serous. There is a cellular-tissue inflam- 
mation, caused by local septic infection ; a septic phlegmon, whose 
products again have great tendency to decomposition, but which 
finally leads to extensive suppuration and necrosis of tissue if the 
patient lives through the blood-infection which always accompanies it. 
The earlier such processes limit themselves, the better the prognosis ; 
with the advance of the local symptoms the danger of death of the 
patient increases. 

With the detachment of dead portions of tissue, we must again 
return to the arteries. An artery may be contused, so as not to be 
fully divided, and the blood continues to flow through it although part 
of its wall is incapable of living, and becomes detached on the sixth 
to the ninth day, or even later. As soon as this occurs, there will be 
a haemorrhage in proportion to the size of the artery. These late 
secondary haemorrhages, which usually come on suddenly, are exceed- 
ingly dangerous, as they attack the patient unexpectedly, sometimes 
while sleeping, and frequently remain unnoticed until much blood has 
escaped. Besides the above manner, late arterial secondary haemor- 
rhage may also result from suppuration of the thrombus, or of the 
wall of the artery. I observed a case of this kind late in the third 
week after a severe operation in the immediate vicinity of the femoral 
artery, in which, however, the artery was not wounded. The bleeding 
began at night ; as the wound looked perfectly well, and the patient 
had for some time slept the whole night, and for some days had 
been promised permission to get up the next day, there was no nurse 
in his private room. He woke in the middle of the night (the 
twenty-second day after the operation), found himself swimming in 
blood, and rung at once for the nurse. She instantly called the assist- 
ant physician of the ward, who found the patient unconscious. He at 
once compressed the artery in the wound, and, while I was being 
called, every thing was done to restore the patient. I found him 
pulseless, unconscious, but breathing, and the heart still beating. 



SECONDARY HAEMORRHAGE. 163 

While I made ready to ligate the femoral artery, the patient died 
he had bled to death. A very sad case ! A man otherwise healthy, 
strong, in the bloom of life, near recovery, must end his life in this 
miserable way ! Rarely has a case so depressed me. Still there was 
no blame anywhere, as it happened all the circumstances had been 
very favorable. The nurse was awake in the next room, the physician 
was only down one flight of stairs in the same house, and was with the 
patient in three or four minutes ; but the bleeding must have existed 
before he woke. He was probably awakened by the feeling of wet- 
ness in the bed. On autopsy, a small spot of the femoral artery was 
found suppurated and perforated. Fortunately, it is not always a 
femoral that bleeds, nor does the bleeding always come so precipi- 
tately, or at night ; hence, we should not become dissatisfied with our 
art from such a rare case. Usually such arterial haemorrhages from 
suppurating wounds are at first insignificant, and soon cease under 
styptics or compression ; but after a few days the bleeding comes on 
more actively, and is more difficult to arrest ; finally, the haemorrhages 
recur more and more quickly, and the patient constantly becomes 
worse. In all severe arterial haemorrhage instantaneous compression 
is the first remedy. Every nurse should understand compressing the 
arterial trunks of the extremities ; but they soon lose their presence 
of mind, as in the above case, and, in their first terror, run themselves 
for the surgeon, instead of compressing the vessel and sending some 
one else. Compression is only a palliative remedy. The bleeding 
may cease after it ; but, if it be considerable, and you are sure of its 
origin, I strongly advise you at once to ligate the artery at the point 
of election, for this is the only certain remedy. You should do this 
the sooner if the patient be already exhausted ; remember that a sec- 
ond or third such bleeding will surely cause death. Hence, in the 
operative course, you should particularly practise ligating the arteries, 
so that you may find them so certainly that you could operate when 
half asleep. In these particular cases much time is unnecessarily lost 
in applying styptics, which usually act only palliatively, or not at all. 
Ligation of arteries is only a trifle for one who knows anatomy thor- 
oughly, and has employed his time well in the operative courses. 
Anatomy, gentlemen I Anatomy, and again anatomy ! A human 
ife often hangs on the certainty of your knowledge in this branch. 

While treating of secondary haemorrhages, we shall speak of 
parenchymatous liaimw^rliages. The blood rises from the granula- 
tions as from a sponge ; we nowhere see a bleeding, spirting vessel. 
The whole surface bleeds, especially at every change of the dressing. 
This may be due to various causes : great friability or destructibility of 
the granulations, that is, their defective organization, may be the fault, 



164 CONTUSED AND LACERATED WOUNDS OF THE SOFT PAETS. 

and this malorganization of the granulations again may depend on con- 
stitutional diseases (hsemorrhagic diathesis, scorbutis, septic or pyaemic 
infection). Still, local causes about the wound are imaginable, as, if 
extensive coagulation gradually formed in the surrounding veins, the 
circulation in the vessels of the granulations would be so affected ; 
the pressure of blood would so increase that not only the serum might 
escape from them, but they would rupture. It is true I have hitherto 
had no opportunity of confirming this by autopsy, but I have seen very 
few of these parenchymatous haemorrhages. The latter explanation 
sounds very plausible ; so far as I know, it originates with Stromeyer. 
He calls such haemorrhages " haemostatic." According to the causes, 
it may be more or less difficult to arrest such haemorrhages ; in most 
cases ice, compression, and styptics, will be proper, or, in severe 
cases, ligation of the arterial trunk, although this occasionally fails. 
This form of haemorrhage occurs chiefly in very debilitated persons, 
who have been exhausted by suppuration and fever, and hence has a 
bad significance for the general state of the patient. 



LECTURE XIII. 

Progressive Suppuration starting from Contused Wounds. — Secondary Inflammations 
of the Wound: their Causes; Local Infection. — Febrile Eeaction in Contused 
Wounds : Secondary Fever ; Suppurative Fever ; Chill ; their Causes. — Treatment 
of Contused Wounds : Immersion, Ice-bladders, Irrigation ; Criticism of these 
Methods. — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open Treat- 
ment of Wounds ; Lister's Dressing. — Prophylaxis against Secondary Inflamma- 
tions. — Internal Treatment of those severely Wounded : Quinine ; Opium. — 
Lacerated Wounds : Subcutaneous Eupture of Muscles and Tendons; Tearing out 
of Muscles and Tendons; Tearing out of Pieces of a Limb. 

The granulating surface that develops on a contused wound is 
generally very irregular, and often has numerous angles and pockets ; 
there is suppuration not only of the surface of the wound, but of the 
surrounding contused parts under the uninjured skin ; hence the 
neighboring skin often appears undermined by pus. The inflamma- 
tion and suppuration often unexpectedly extend between the muscles, 
along the bones, and in the sheaths of the tendons, because these 
parts were also affected by the injury. The process of inflammation, 
once excited, creeps along, especially in the sheaths of the tendons 
and in the cellular tissue ; new collections of pus form, superficially 
or in the depths ; the injured part remains swollen and cedematous ; 
on the surface the granulations are smeary, yellow, swollen, and 
spongy. When we press in the vicinity of the wound, the pus flows 



INFLAMMATION OF CONTUSED WOUNDS. 165 

slowly from smaller or larger openings, which have formed sponta- 
neously, and this pus which has remained for a time in the depth is 
not infrequently thin and bad smelling. Should the process con- 
tinue long, the patient becomes more miserable and weak ; he has 
high and continued fever. A wound, which perhaps at first appeared 
insignificant, perhaps about the hand, has extended horribly, and in- 
duced severe general disturbance. The sheaths of the tendons about 
the hands and feet are particularly favorable for the extension of deep 
suppurations, which readily attack the joints, while, on the other 
hand, articular inflammations of the extremities readily attack the 
sheaths of the tendons. These states may take a very dangerous turn, 
and you should be constantly on your guard. From the constant pu- 
rulent infection, as well as from the daily loss of pus, even the strong- 
est man may emaciate in a few weeks, and die with symptoms of 
febrile marasmus. 

We now know two forms of inflammation which may attack con- 
tused wounds : 1. Rapid, progressive, septic inflammation, which 
begins about the wound during the first three or four days (rarely in 
less than twenty-four hours, and just as rarely after the fourth day), 
and which is caused by local infection from parts that decompose in 
the wound. 2. Progressive purulent inflammation, which is particu- 
larly apt to occur in wounds of the hands or feet during the cleansing 
of the wound from necrosed shreds of tissue, without the pus becom- 
ing ichorous, although butyric acid often formed in it. 

But, even when the wound has entirely cleaned off and granu- 
lated, when the inflammation is bounded, and the wound begins to 
cicatrize, new inflammation, with severe results, may begin. These 
secondary progressive inflammations of suppurating wounds, occur- 
ring even several weeks after the injury, and sometimes coming as 
unexpectedly as lightning from a clear sky, are of great importance, 
and are sometimes very dangerous. They are almost always of sup- 
purative nature, and may be fatal from intense, phlogistic, constitu- 
tional infection, just as often as the primary progressive suppurations. 
In some cases, also, they prove dangerous from their location, as in 
wounds of the head. These cases are so striking and tragical that 
we must give them special consideration. Suppose you have brought 
a case of severe crushing of the leg, with fracture, successfully 
through the first dangers. The patient has no fever; the wound 
granulates beautifully, and has even begun to cicatrize. Suddenly, in 
the fourth week, the wound begins to swell ; the granulations are 
croupous or spongy, the pus thin; the whole limb swells. The pa- 
tient again has high fever, perhaps repeated chills. The symptoms 
may pass off, and every thing go on in the old track ; but it often 



166 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

turns out badly. In a few days the strongest man may become a 
corpse. Some time since such a case occurred in Zurich, in a fellow- 
student with a wound of the head ; it may serve you as a warning 
example. The young man received a blow over the left vertex ; the 
bone was injured very superficially ; the wound healed quickly by 
first intention ; only a small spot continued to suppurate. As the 
patient felt quite well, he paid no attention to the little wound, and 
went about as if perfectly well. Suddenly, in the fourth week, after 
a walk, he had severe headache and fever. The following day there 
was about a teaspoonful of pus collected under the cicatrix, which 
was evacuated by an incision. This did not have the desired beneficial 
effect on the general condition ; the fever remained the same. In the 
evening delirium began, then sopor. The fourth day the previously 
vigorous man was dead. It was easy to diagnose that there had been 
suppurative meningitis. This was proved on autopsy. Although at the 
spot, as big as a pea, where slight suppuration had been so long 
kept up, the bone was but slightly discolored by purulent infiltration, 
still the suppuration on, in, and under the dura mater was greatest at 
the part exactly corresponding to this point ; so that the new inflam- 
mation undoubtedly started from the wound. A short time since, 
here in Vienna, in private practice, I saw a perfectly similar case, also 
fatal, in a man who several weeks previously had received an appar- 
ently insignificant wound, from a piece of a soda-water bottle that 
burst, at the upper part of the forehead, along the margin of the 
hairy scalp. 

The inflammations occurring under such circumstances, as already 
remarked, are usually of a diffusely purulent character, but other 
forms accompany it, or occur spontaneously, such as diphtheritic in- 
flammation of the granulations {traumatic diphtheria, hospital gan- 
grene), inflammation of the lymphatic trunks (lymphangitis), and a 
specific form of capillary lymphangitis of the skin, erysipelas or ery- 
sipelatous inflammation ; and, lastly, inflammation of the veins (phle- 
bitis). Not infrequently all of these processes may be seen mixed 
together. We shall hereafter study these diseases more accurately, 
under accidental traumatic diseases. But here we must consider the 
causes of these secondary inflammations, before passing to the treat- 
ment of contused wounds; and, in so doing, we must anticipate 
somewhat. All of these forms of inflammation, and their reflex 
action on the organism, are so intertwined, that it is impossible to 
speak of one without mentioning the other. 

As causes of secondary inflammations in and around suppurating 
wounds that have begun to heal, we may mention the following : 1. 
Excessive flow of blood to the wound, such as may be induced by too 



INFLAMMATION OF CONTUSED WOUNDS. 167 

much motion of the part, or by great bodily exertion, as well as by 
exciting drinks, mental agitation, in short, by any great excitement ; 
in wounds of the head, such congestions are particularly dangerous. 
Congestion, as caused by too tight bandages, may prove injurious in the 
same way. 2. Local or general catching cold ; about catching cold as 
a cause of inflammation we know little more than the simple fact that, 
under certain circumstances, which cannot be accurately defined, a 
sudden change of temperature induces inflammations, especially in a 
locus minoris resistentiw of an individual ; in a wounded person the 
wound is always to be considered as a locus minoris resistentim. The 
danger of catching cold after injury was certainly over-estimated 
formerly ; I hardly know of any certain examples. 3. Mechanical 
irritation of the wound. This is very important. The pus from the 
wound is never reabsorbed by the uninjured granulations ; but, if they 
be destroyed by mechanical manipulations, as by improper dressings, 
much probing, etc., which cause the wound to bleed frequently, new 
inflammations may be induced. Any foreign bodies in the wound 
might prove serious in this way, such as pieces of glass, lead, or iron, 
or sharp splinters of bone ; for the first changes which take place in 
the wound, the vicinity of such foreign bodies is less important, but, 
when, from muscular movements, and the motion communicated to the 
tissue from the arteries, the sharp angles of a foreign body keep up 
constant friction in a part, severe inflammation occurs after a time. 
4, Chemical ferments y here I mention first soft foreign bodies, such 
as pieces of clothing, paper wads, which have entered the tissue 
through gunshot wounds ; these substances become impregnated with 
the secretions from the wound, then the organic material (paper, wool) 
decomposes, and acts as a caustic and ferment in the wound. I am in- 
clined to believe that necrosed splinters of bone also act rather as chem- 
ical than as mechanical irritants ; in the Haversian canals, or medullary 
cavity, they always contain some organic decomposing substance ; all 
such pieces of bone have a putrid smell when extracted ; if the sur- 
rounding granulations were partly destroyed by the sharp angles of 
such a fragment of bone, the putrid matter passes from it into the 
open lymphatic vessels, or possibly even into the blood-vessels, and 
so induces, not only local, but, at the same time, constitutional infec- 
tion. Necrosed tags of tendon and fascia at the bottom of suppu- 
rating wounds may induce the same results, although this rarely hap- 
pens. In hospitals, especially, there are some rare cases where we can 
find none of the above causes ; such occurrences naturally induce pe- 
culiar alarm, and attempts have been made to explain them by certain 
injurious influences of the hospital atmosphere, especially such as is 
filled with the smell of pus. Many circumstances speak against the 



168 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

view that the injurious substances are gaseous ; by good ventilation 
the air of the hospital may be kept pure, but this is no protection 
against the affection in question ; moreover, we cannot excite inflam- 
mations by any of tne gases developing from pus or putrefying sub- 
stances, unless, perhaps, by sulphuretted hydrogen, when dissolved in 
water and injected into the subcutaneous cellular tissue. Putrid fluids 
and pus from other patients would not intentionally be brought in 
contact with wounds ; we have previously shown that the vicinity of 
the wound may, under some circumstances, be infected by pus from 
the wound, and excited to new inflammation. Hence there is little 
left but the supposition that the injuriously-acting substances are of a 
molecular, dust-like nature ; they may float about in the air of the 
hospital, but they may also adhere to the bandages, charpie, com- 
presses, etc., with which we dress the wounds, or to the instruments, 
forceps, probes, sponges, etc., with which we touch the wound. May 
they not be fungi, or other organic germs, whose nature we do not at 
present know, like those we know to excite fermentation ? This is 
possible, for in every cubic foot the air holds quantities of such germs, 
and in the hospital such organic germs of animal or vegetable nature 
might develop in the secretions from wounds, in the sputum or 
excrement, and the more so in proportion as the readily-decomposing 
secretions and excretions are collected in hospitals, or in badly- 
built water-closets and sewers. On this point we can only haz- 
ard conjectures, while we may make experiments with dry putrid sub- 
stances and dry pus, by powdering them, and then introducing them 
into the healthy tissue of animals. Such experiments have been made 
by 0. Weber and myself, and they have shown that both animal and 
vegetable putrid, dry substances, as well as dry pus, induce inflam- 
mation ; if we pulverize these substances, stir them up quickly with 
water, then inject them into the subcutaneous cellular tissue of ani- 
mals, they will excite progressive inflammation, just as putrid fluids 
and fresh pus do. Now, it must at once be acknowledged that in a 
hospital such injurious dust-like bodies may readily cling to dressings 
and bedclothes ; possibly, also, to instruments. In short, it is possible 
that the direct injurious influence of hospital air on a wound may be 
due to fine dust-like particles of putrid or purulent matter coming in 
contact with it from the dressings or instruments. There can be no 
doubt that such injurious materials may enter the body in other ways 
besides through wounds, as through the lungs ; indeed, we explain the 
occurrence of all so-called infectious diseases by the entrance in the or- 
ganism of substances which have a sort of fermenting influence on the 
blood ; but, whether the morbid materials which excite the infectious 
diseases chiefly occurring in the wounded be different from those arising 



INFLAMMATION OF CONTUSED WOUNDS. 169 

from the wound itself, may be a disputed point, so far as we at present 
know. We shall return to this point when speaking of accidental 
traumatic diseases. You will suspect me of contradicting myself here, 
because in yesterday's lecture I said that no molecular body could en- 
ter the tissues through an uninjured granulation-surface. I must still 
claim this as usual ; a strong, uninjured granulation-surface is a de- 
cided protection against infection through the wound. But, when the 
infecting material itself is very irritating, so that it destroys the 
granulating surface by causing decomposition, a passage-way is opened 
for the poison to enter the tissues. Still more, there are certain sub- 
stances which are carried into the granulation-tissue, and perhaps 
even further, by the pus-cells. If you sprinkle a granulating surface 
on a dog with finely-powdered carmine, some cells take up the small 
carmine granules and wander with it into the granulation-substance ; 
after a time you find cells with carmine in the granulation- tissue. I 
consider this an abnormal retrograde movement of the pus-cells, which 
we generally believe to pass from the granulation-tissue to the surface 
of the wound ; it is true, no one has seen this. Nevertheless, from the 
above experiment, it is evident that even molecular substances may 
pass from without into the tissue of the edges of the wound, and, if 
these substances be very decomposable or cauterant, they will excite 
active inflammation. But all of the millions of molecular organisms 
in the atmosphere are not taken up by the wound, nor do they each 
induce inflammation. My belief is that all micrococci do not neces- 
sarily have a phlogogenous action, but only those which are formed 
in certain products of inflammation, such as decomposing pus or 
fluids of the body, putrid urine, etc., and which have there ab- 
sorbed the ferment. This is the most frequent cause of micrococ- 
cus in hospital ; hence its development there is to be combated with 
particular energy. I do not believe that these substances, whether 
lifeless or living molecules, are always the same, but I think they 
are very numerous, as are the causes of inflammation generally ; 
they may all have certain chemical peculiarities in common, as we 
might suppose from their similar action, although we know nothing 
about them, except this action ; they also differ somewhat in their 
mode of action on this or that tissue ; the absorbability of such sub- 
stances may vary with the part of the body, and possibly, also, with 
the individual ; but the large number of these injurious substances 
is, in fact, small as compared with the innumerable variety of organic 
substances generally. 

Febrile reaction is usually greater from contused than from incised 
wounds; according to our view, this is because, from the decomposi- 
tion, which is much more extensive in crushed than in incised parts, 



HO CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

far more putrid matter enters the blood. If in any case the putrid 
matter is particularly intense, or very much of it is taken up (es- 
pecially in diffuse septic inflammations), the fever assumes the charac- 
ter of so-called putrid fever ; the state thus induced is called septi- 
cemia ; we shall hereafter study it more closely. If the suppurative 
inflammation extends from the wound, there is a corresponding- con- 
tinued inflammatory or suppurative fever ; this has the character of 
remittent fever with very steep curves and occasional exacerbations, 
mostly due to progress of the inflammation, or to circumstances that 
favor the reabsorption of pus. If we call the fever, that often, but 
not always, accompanies traumatic inflammation, simple traumatic 
fever ^ we may term the fever that occurs later " secondary fever" or 
" suppurative fever" This may immediately succeed the traumatic 
fever, if the traumatic inflammation progresses regularly; but the 
traumatic fever may have ceased entirely, and the wound be already 
healing, and when new secondary inflammations, of which we have 
fully treated, attack the wound, they are accompanied by new suppu- 
rative fever ; in short, inflammation and fever go parallel. Occasion- 
ally, indeed, the fever appears to precede the secondary inflammation, 
but this is probably because the first changes in the wound, which 
may be only slight, have escaped our observation. At all events, on 
every accession of fever that we detect, we should at once seek for the 
new point of inflammation, which may be the cause. I am far from 
asserting that it is necessary to measure the temperature in all cases 
of wounds ; undoubtedly any experienced surgeon, accustomed to 
examine patients, would know the condition of his patient without 
measuring the temperature, just as an experienced practitioner may 
diagnose pneumonia without auscultation and percussion ; but no one 
who understands the significance of bodily temperature doubts that 
its measurement may sometimes be a very important aid to diagnosis 
and prognosis. It is with it as with every other aid to observation ; 
it is not difficult to detect a dull percussion-sound in the thorax where 
it should not exist ; but the art and science of determining the sig- 
nificance of this dull percussion-sound in any given case must be 
learned ; so, too, with measurement of temperature : for instance, we 
must learn whether a low temperature in any given case be of good 
or bad omen. I shall enter into more detail on this subject in the 
clinic. 

Experience teaches that secondary fever is often more intense 
than primary traumatic fever. While it is most rare for the latter to 
begin with a chill (a slight chilliness after great loss of blood and 
severe concussion is not usually accompanied by high temperature), 
it is not at all so for a secondary fever to commence with severe "chill." 



INFLAMMATION OF CONTUSED WOUNDS. 17 1 

We shall at once study this peculiar phenomenon more attentively. 
Formerly the chill was always regarded as essentially dependent on 
blood-poisoning ; if we now regard fever generally as due to intoxi- 
cation, we must seek some special cause for the chill. Observation 
shows that the chill, which is always followed by fever and sweating, 
is always accompanied by rapid elevation of temperature. If we ther- 
mometrically examine the temperature of the blood of a patient with 
chill, we find it high and rapidly increasing, while the skin feels cool ; 
the blood is driven from the cutaneous vessels to the internal organs. 
As already remarked, Traube considers this as the cause of the ab- 
normal febrile elevation of temperature. We shall not discuss this at 
present ; at all events, there is so great a difference between the air 
and the bodily temperature that the patient feels chilled. If we un- 
cover a patient with fever, who lies wrapped up in bed and does not 
feel chilly, he at once begins to shiver. Man has a sort of conscious 
feeling for the state of equilibrium in which his bodilv temperature 
stands to the surrounding air ; if the latter be rapidly warmed, he at 
once feels warmer, if it be rapidly cooled, he at once feels cool, chilly. 
This trivial fact leads us to another observation. This sensitiveness 
for warmth and cold, this conscious feeling of change of temperature, 
varies with the individual ; it may also be increased or blunted by the 
mode of life ; some persons are always warm, others ever too cold, 
while for others the temperature of the air is comparatively a matter 
of indifference. The nervous system has much to do with this. Ac- 
curate studies of Traube and Jbchmann have in fact shown that the 
nervous excitability of an individual has a great effect as to whether, 
in a rapid elevation of temperature of the blood, the change will be much 
perceived or not ; hence that in torpid persons, in comatose condi- 
tions, chills do not so readily occur with fever, as they do in irritable 
persons already debilitated by long illness. I can only confirm this 
from my own observation. Although I have a general idea that, 
where there is sufficient irritability, rapid elevation of temperature 
and chill chiefly occur when a quantity of pyrogenous material enters 
the blood at once, still I cannot deny that the quality of the material 
is also important. We know nothing of this quality chemically, but 
we may conclude that it has varieties, because both the fever-symp- 
toms and their duration often vary greatly, and that this does not 
solely depend on the peculiarities of the patient. According to my 
observations, in man reabsorption of pus and recent products of in- 
flammation is more apt to induce chills than is absorption of putrid 
matter, which is perhaps more poisonous and dangerous. I do not 
wish to weary you with too many of these considerations, and so 
shall return to the subject in the section on general accidental trau- 



172 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

matic and inflammatory diseases, which you may regard as a continu- 
ation of this study of fever. I will only remark here that both the 
septic and purulent primary and secondary inflammations, with their 
accompanying fever, may also occur from incised wounds, especially 
after extensive operations (as amputations and resections). We have 
considered this condition along with contused wounds, because it 
complicates them much more frequently than it does ordinary incised 
wounds. 

Now we pass to the treatment of contused wounds. 

In many cases contused wounds require no more treatment than 
incised wounds ; the conditions for healing exist in both. Hence, in 
a contused wound it is only necessary to anticipate any accidents, or 
at all events to master them so that they may not become dangerous. 
In both respects we may do something. Formerly it was always sup- 
posed that the air with its oxygen and its ferments particularly favored 
the decomposition of dead, organic bodies, hence of contused parts ; 
to prevent this, the wound was excluded from the air, and, to prevent 
warmth acting as an aid to decomposition, the wounded part was kept 
cool. We attain both objects by placing the injured part in a vessel 
of cold water, whose temperature is always kept cool by ice. This 
treatment is called " immersion " or " continued cold-water bath." I 
first saw this used with excellent effect by my earliest teacher in 
surgery, Prof. JBaum, in G5ttingen. This mode of treatment is only 
really practical in the extremities ; in the leg as high as the knee, and 
in the arm to a little above the elbow. We place suitably-constructed 
arm and foot vessels filled with cold water in the patient's bed, and 
have the wounded extremity kept in it day and night. The patient's 
position should be such that he lies easily, and that the extremities 
may never press too hard on the edge of the vessel. This is all very 
simple ; you will often see this apparatus in my clinic. In the most 
common injuries of the hand, a basin with cold water is sufficient in 
private practice. In parts which cannot be kept in water in this sim- 
ple way, we try to exclude the air by applying moist linen compresses, 
which readily adapt themselves to the injured part ; over these we 
apply a rubber bag (or a bladder) filled with ice, which is to be re- 
placed as it melts. It is still more efficacious to wrap up a limb well 
and pack it in a vessel with ice. A third method of applying cold 
water is the so-called irrigation. For this we require special appara- 
tuses. The injured extremity is laid in a tin trough, supplied with an 
escape-tube. Above the extremity we place an apparatus from which 
a continued stream of cold water drops from a moderate height on 
the wound. Lastly, we may simply cover the wouDd from time tc 
time with compresses dipped in ice-water. 



TREATMENT OF CONTUSED WOUNDS. 173 

I have seen all these modes of treatment in practice. Here is my 
opinion of them : none of them act certainly as prophylactics. In 
contused wounds of the hands and feet the water-bath is best ; for, 
under this treatment, extensive suppuration is rarest. To attain the 
same favorable results by the ice-treatment, we must cover not only 
the wound but the parts around with the ice-bladders ; pack the parts 
in ice. 

In applying cold-compresses, we shall only really obtain the effect 
of cold if we change the compresses every five minutes, for they 
warm very quickly, and the usual treatment with cold-compresses 
actually amounts to nothing more than keeping the parts moist; 
hence, this is, strictly speaking, no peculiar mode of treatment ; never- 
theless, as I have already remarked, most small contused wounds heal 
under it spontaneously, without our placing them under unnatural 
conditions by the use of cold. Irrigation is not a bad plan of treat- 
ment, but it is troublesome, and it is often difficult to avoid wetting 
the bed ; the condition of the wound subsequently does not differ 
from that in the more simple treatment by immersion or ice, so that I 
have not felt obliged to resort to irrigation. In France, this method 
is practised and highly esteemed by some surgeons. 

Apart from the prevention of accidents, for which all remedies are 
as useless here as venesection is in pneumonia, we have still in the 
above modes of treatment important means for combating the usual 
local accidents. I have still a few special remarks to make about the 
water-bath. As we here leave out of consideration injuries of the 
bones and joints, I know of no contraindication to it in contused 
wounds of the hand, forearm, foot, and leg. In most cases of these 
injuries the bleeding is so slight, and ceases so soon spontaneously, 
that the patient can place the extremity under water very soon if not 
immediately after the injury, without the occurrence of haemorrhage ; 
but the blood clinging to the part should first be washed off, the water 
itself be perfectly pure and transparent, and, if it becomes clouded by 
the secretion of the wound, it should be kept clear by frequent re- 
newals. Even when the wound is two or three days old, the water- 
bath may still be employed with advantage ; later, it is of little use. 
If the patients lie comfortably in bed with the tub, they are more 
contented and free from pain under this treatment than under any 
other. The temperature of the water may vary greatly without much 
changing the condition of the wound ; only ice temperature, and the 
high temperature obtained by cataplasms, cause a somewhat different 
appearance ; but from 54° to 90° or 100° F. it does not vary much in 
looks. Perhaps suppuration comes on a little sooner at the higher 
temperature, but the difference is not great. Hence, we may adapt 



174 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

the temperature of the water to the feelings of the patient. At first 
the patients generally prefer a lower temperature (54°-68° F.), later 
a rather higher one (88°-95° F.) ; but there are also patients who, 
even during the first day, complain of chills if the temperature of the 
water falls below 68° F. Hence we see that it is rather indifferent 
whether we employ warm or cold water baths. In some persons, on 
the third or fourth day, there arises a state which renders immersion 
unbearable, that is, swelling of the epidermis of the hands or feet, 
and the accompanying tense, burning sensations, which somewhat re- 
semble the action of a blister. The thicker the epidermis, the more 
disagreeable this accident. It may be avoided by rubbing the injured 
extremity with oil, before placing it in the water, and adding a hand- 
ful of salt to the water ; this does no harm to the wound. An im- 
portant question is, How long shall continued immersion be employed ? 
Rules for this can only be given after considerable experience. I have 
found from eight to twelve days enough. After this we may leave 
the limb out of the water at night, enveloping it in a moist cloth cov- 
ered with oiled silk ; a few days later we may employ this dressing 
during the day also, and use the water-bath only morning and even- 
ing, or mornings alone, leaving the limb in it half an hour or an hour 
to bathe and cleanse it. Finally, we leave off the water entirely, and. 
treat the granulating, cicatrizing wound after the simple rules already 
given. The changes in wounds under this treatment are somewhat 
different from those previously described. In the first place, all goes 
on much slower ; sometimes, especially in the treatment with the 
cold-water bath, the contused wound looks as fresh for four or five 
days as when first received. The same thing is noticed for some time 
under the treatment with bladders of ice. This is not so astonishing 
as it at first seems, for, as is well known, decomposition of organic 
substances goes on more slowly in water than in the air. Subse- 
quently the pus usually remains on the wound as a flocculent, half- 
coagulated layer, and must be washed or syringed off to obtain a view 
of the subjacent granulations, which are infiltrated with water, and 
often quite pale. This observation is very important, and protects us 
from illusions in regard to the efficacy of the water-bath in deep sup- 
purations ; we might suppose that the pus flowed from the wound 
directly into the water and was there diffused, so that it would simply 
be necessary to place the suppurating part in water to have it always 
clean. The water-oath does not favor the escape of pus / it rather 
prevents it. Pus on the granulations, or in cavities, coagulates at 
once on contact with water, and usually remains on the wound ; wash- 
ing or syringing is necessary for its removal. Swelling of the granu- 
lations entirely prevents the escape of pus from deep parts. Hence 



TREATMENT OF CONTUSED WOUNDS. 1V5 

we see, where there is suppuration from a cavity, that the water-bath 
is of no use, but is even injurious, and that an extremity should at 
once be removed from the water as soon as deep progressive inflam- 
mations extend out from the wound. By this we do not mean to ex- 
clude a half-hour's bath of the part. Should there be no progressive 
inflammations, there would be no particular harm from leaving the 
wound in the water for two, three, or four weeks, only the healing 
would be much retarded. In the water the parts remain greatly 
swollen ; the granulations are full of water (artificially cedematous), 
pale, and cicatrization and contraction of the wound will not occur. 
If you then remove the extremity from the water, the wound soon 
contracts ; in a few days the granulations look stronger, and the pus 
better ; healing progresses. 

Now I must say something about the continued treatment by ice. 
Suppose you cover the contused wound from the first with a bladder 
of ice ? Here, also, you will find that the crushed parts are very 
slowly detached, and that no smell arises from the wound, unless large 
masses of tissue become gangrenous ; to prevent the latter, if possi- 
ble, I apply charpie, or a thin compress wet with chlorine-water, next 
to the wound, and have it frequently renewed. If we now continue 
the treatment four to six weeks, all the necessary changes in the 
wound will go on very slowly and sluggishly ; the cicatrization and 
contraction of the wound are also very slow under the influence of 
the ice, and hence this method is entirely out of place if we desire to 
hasten the process of healing. Most surgeons believe that we may 
prevent severe inflammations by applying bladders of ice to the re- 
cent wounds ; hence you will find ice applied at once to most cases 
of contused wounds. Occasionally this proves very grateful to the 
patient, by relieving his pain, but it does not seem to me a prophy- 
lactic antiphlogistic ; for centuries, men have sought such a prophy- 
lactic, just as they have for one for inflammations of internal organs. 
By the application of ice to recent wounds, we can neither prevent 
sanio-serous infiltration, nor suppurative inflammations, at least, this 
is my opinion. As already stated, many believe in the prophylactic 
action of ice, and are convinced that by this means only they can save 
persons badly injured. I have become satisfied that the dangerous 
complications to wounds often occur in spite of the ice, and are not 
unfrequently wanting when ice is not used, when from the nature of 
the wound they might be expected. From what has been said, you 
might almost suppose that I consider ice an inefficient remedy that 
may be dispensed with, still, you will see it much employed in my 
clinic ; in my opinion, cold is one of the best antiphlogistics, especially 
in inflammation of an external part where it can act directly. Hence, 



1 76 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

ice is proper where there is inflammation, especially if accompanied 
by great fluxion, with a tendency to suppuration of the wound. If 
inflammation of the cellular tissue, the sheaths of tendons or muscles, 
or of a neighboring joint begin, you should apply ice to the inflamed 
part, and thus avoid the excessive hyperemia, and so the increase ot 
the inflammation. You think I am here contradicting myself, when I 
say that ice is of no use in preventing the development of inflamma- 
tion about a wound, but it is of use in lessening the commencing inflam- 
mation and preventing its spread. But let me explain this by an ex- 
ample, and you will readily see the difference. When any one suffers 
from headache, he certainly would not think of being bled for every 
attack, to prevent inflammation of the brain; but, if the latter be 
really developing, venesection may be a very efficacious remedy to 
arrest its further development and spread. By the aid of ice, we do 
not always succeed in arresting the suppuration extending from the 
wound, but occasionally the ©edematous skin grows redder, becomes 
painful, and, when you press on it, a thin, serous, or sometimes quite 
consistent pus occasionally flows slowly from some of the angles of the 
wound. Under such circumstances, the retained pus, especially if 
bad smelling and ichorous, must be set free, and allowed to flow 
unobstructedly ; for this purpose, deep incisions should be made in the 
soft parts, and then kept open. When this should be done, and how 
it may best be done in individual cases, you will have to learn in the 
clinic. For probing such suppurating cavities, I prefer a slightly-curved 
silver catheter, which I pass through the wound to the end of the 
canal, then press the end up against the skin and here make the in- 
cision. For enlarging these so-called counter-opening 's, just as in 
other wounds, you use a tolerably long probe-pointed knife, straight 
or curved (JPottfs knife). As a rule, the counter-opening should not 
exceed an inch in length ; if necessary, we may make several of this 
length; in such cases there is usually no use in dividing the soft parts 
of the forearm or leg longitudinally, as was formerly taught. To prevent 
these new openings from closing again too soon, which, however, rarely 
happens, you may introduce several silk threads through the pus canals, 
tie the ends together, and leave them for a time. In place of these 
setons of silk or linen threads, caoutchouc tubes, with numerous lateral 
openings, have recently been used ; they have received the name of 
drainage-tubes, an expression taken from agricultural technology ; 
sometimes, at least, these tubes facilitate the escape of pus very well, 
but their principle is not new, nor can we accomplish such wonders 
with them as is claimed by Chassaignac, their inventor, who has 
written a book in two thick volumes about them. In making these 
counter-openings, you will not unfrequently strike on dead shreds of 
tendon or fascia, which should then be removed. 



TREATMENT OF CONTUSED WOUNDS. 177 

The skilful use of the above remedies is an art of experience; 
what you cannot accomplish with them in suppuration, you will not 
accomplish with any thing else. 

One of our colleagues of former days would shake his head doubt- 
fully, if he heard that we had talked so long about the treatment of 
contused wounds and secondary suppurations, without having men- 
tioned cataplasms. " Tempora mutantur ! " Formerly cataplasms 
belonged to suppurating wounds as undoubtedly as the lid to the box, 
and now, three or four weeks may pass in my wards without cata- 
plasms being once employed for their original uses. The employ- 
ment of moist warmth, whether in the form of cataplasms or of thick 
cloths dipped in warm water, is useless in the treatment of contused 
wounds, and, in the treatment of secondary suppurations, it is occa- 
sionally injurious ; under them the wounds become permanently re- 
laxed, the soft parts swell, and healing is not advanced. Moreover, 
cataplasms only truly act as moist warmth when often renewed ; their 
renewal is tiresome, the poultice easily sours, or may be scorched, and 
finally, the whole mess cannot be carefully watched in a hospital ; a 
cataplasm covered with pus may be removed, new poultice added, 
and it may then be placed on another patient. In some hospitals at 
least half of the surgical patients wear poultices ; hundred-weights of 
grits and flaxseed, etc., for poultices, are used monthly in the surgical 
wards ; they are almost banished from my wards ; as occasion offers, 
I shall show you the cases where they may be used with advantage. 

Hence, little as I can recommend the use of moist warmth as 
the ordinary treatment of wounds, I consider it very suitable in 
those where there is an extensive hard (fibrinous diphtheritic) infil- 
tration of the cellular tissue. In these cases the moist warmth is not 
only pleasant to the patient, by rendering the tense skin soft and 
pliable, but it appears to aid removal of the hardened inflammatory 
products, either by their reabsorption or breaking down into pus. 
In such cases I apply warm moist cloths covered by some waterproof 
material. 

Hitherto I have not mentioned that the absolute rest of an injured 
part is always necessary ; it may seem singular that I should mention 
it at all ; you may think this should be considered a matter of course. 
I lay particular stress on it, because injurious substances are taken 
from the wound into the blood ; hence every muscular movement, and 
every consequent congestion of the wound, in short, every thing that 
drives the blood and lymph more strongly into the vicinity of the 
wound, may eventually prove injurious. 
12 



178 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

Nor is an elevated position of the injured part to be neglected where 
it can be tried. You may readily prove on yourselves that gravity has 
something to do with the movement of the blood ; if you let your arm 
hang perfectly relaxed for five minutes, you will feel a heaviness in the 
hand, and the veins on the back of the hand will look swollen ; if, on 
the contrary, you elevate the hand for a time, it will become whiter 
and smaller. While debilitated persons are lying in bed, in the morn- 
ing, for instance, their faces look fuller than when they have borne 
the head erect for the day. Recently, VblJcmann has strongly recom- 
mended vertical suspension of the arm as a powerful antiphlogistic 
in inflammations of the hand; consequently, I have employed this 
method, and in cases of cutaneous inflammations have found it very 
efficacious ; it appears to do less good in deep inflammations, as of the 
wrist. 

Hereafter, the water-bath, ice-treatment, and cataplasms, will prob- 
ably give place to the open treatment of wounds, from which I have 
seen very good results in contused as well as in incised wounds (p. 95), 
I did not say this at the commencement of the section, because I do 
not consider my experience of this mode of treatment sufficiently ex- 
tensive for me to give a final judgment. The dreaded access of air 
to the surface of the wound, even the air of badly-ventilated hospitals, 
is not, in my opinion, so injurious as dressings and sponges of doubt- 
ful cleanliness ; the idea that air is injurious to suppurating wounds 
rests chiefly on the observation that the entrance of air to abscess 
cavities with rigid walls, and into serous sacs, usually induces sup- 
puration ; apart from the fact that, in many of these cases, it is not 
proved that it is indeed the entrance of air which excites the inflam 
mation, we must also attribute much of the blame to the fact that in 
the pus-sacs the air is warmed and impregnated with watery vapor 
from the pus ; this enclosed air now becomes a true hatching-place for 
those minute organisms which cause decomposition, and which are 
always more or less present in the atmosphere. Every observing 
housekeeper knows that meat or game hanging in the open air spoils 
far less readily than when shut up in a cupboard, even when the air 
in the latter is kept cool by ice. Free air does no harm to the wound, 
imprisoned air is very dangerous. I have already mentioned (p. 96), 
that a wound treated openly from the start has no bad smell, unless 
large shreds of tissue on it become gangrenous ; in accordance with 
this also, flies do not deposit their eggs in open wounds, while they 
are apt to creep into dressings to do so ; I must say these observa- 
tions surprised me very agreeably, because I feared that flies would 
render the open treatment of wounds impossible in summer. The 
longer I carefully try the open treatment of wounds, the more it sat- 



TREATMENT OF CONTUSED WOUNDS. 179 

isfies me. No method guarantees a perfect immunity from acci- 
dental traumatic diseases, and even in the open treatment of wounds 
there may be superficial adhesions and formation of pockets in which 
decomposition of the secretion may occur. We must learn to antici- 
pate such things. 

Many surgeons now prefer the method of occlusion by thoroughly 
disinfected dressings and early application of drainage-tubes for car- 
rying off secretion, after Lister's method. It is asserted that by this 
means a milder course is secured, as in subcutaneous contusions ; 
that the shreds of dead tissue do not decompose, but dry up without 
smell and are thrown off with very little suppuration; that the 
blood-clots are either directly organized or escape from the wound 
as odorless gray crumbs ; that acute septicaemia and progressive sup- 
purations never occur ; and that the severe accidental traumatic dis- 
eases, of which we shall hereafter speak, are never developed. I 
recommend this method to you most warmly. 

In general I would advise you, as students and practitioners, to 
study and accurately learn one of the modes of treatment recom- 
mended to you, and not to be easily led off from your therapeutic 
principles. In your practice employ what you have well and thor- 
oughly learned. Believe me, your patients and yourselves will thus 
come out the best. 

In the treatment of secondary inflammation, most careful prophy- 
laxis is to be recommended ; avoidance of congestion of the wound, 
catching cold, all mechanical and chemical irritations, and especially 
infection. Hereafter, when speaking of accidental traumatic diseases 
in general, we shall state what may be done in the latter respect by 
ventilation and proper use of the room in the hospital. For avoiding 
local infection of the wound by dressings or instruments, we would 
give the following advice: Be exceedingly careful in the dressings, 
cleansing the wound, choice of compresses, charpie, and wadding ; al- 
ways see to the most perfect cleanliness of the mattresses, straw beds, 
coverings, oiled muslin, parchment-paper, and in short of every thing 
about the patient. The bleeding of the wound on dressing should be 
avoided by carefully syringing it with EsmarcKs wound-douche, of 
which there should be two or three in every ward ; we should never 
apply dry compresses, charpie, or wadding to the wound, but should 
previously wet all these articles in solution of chloride of lime or other 
antiseptic, and later, when the wound begins to cicatrize, with lead- 
water ; and for removing the pus we should never use sponges, nor 
should we use them in operating, but do it all by syringing or by 
wiping off with wadding wet with water or chlorine-water ; if we 
cannot avoid the use of sponges, they should be new ones, and disinfect 



180 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

them at once with hypermanganate of potash or carbolic acid. Or- 
ganic beings never develop in chlorine-water (aqua chlori, with equal 
parts of water), solution of chloride of lime (chloride of lime two 
drachms, water one pint), nor do they in lead-water, in solution 
of acetate of alumina (alum 20, acetate of lead 35, water 400), of 
permanganate of potash, or in sulphide of soda 50, glycerine 25 ? 
water 450 (Polli, Minnich). Lister has recommended carbolic acid 
as a peculiarly efficacious antiseptic ; it may be diluted with oil, 
glycerine, or water, or made into a paste with chalk, and then spread 
on tin-foil, to make an air-tight covering for the wound. " Deodor- 
izing powder" (coal-tar and plaster of Paris), sprinkled dry on putre- 
fying sores, is also good where the wound is not too deep. These 
different modes of application, under the name of " Lister's dress- 
ing," have been regularly tried, and it is a good thing for the pro- 
fession to study and become thoroughly acquainted with any method 
of treatment. Lister has accomplished one good, at least, in having 
directed attention to the antiseptic treatment, and given it a definite 
practical value. I consider carbolic acid as a very serviceable anti- 
septic, but have not found it to possess any special advantage over 
the remedies and modes of treatment above mentioned. You must 
pay special attention to the instruments with which you touch the 
wound, such as probes, forceps, knives, scissors ; every thing should 
be wiped before being used, or, if it be at all suspicious, it should 
be quickly rubbed with cleaning powder. In order to carefully ob- 
serve all these precautions, you must be perfectly satisfied of their 
necessity. 

If, in spite of all our care, decomposition, gangrene, or phleg- 
monous inflammation has started in the contused wound or its vicin- 
ity, we must abandon the protective dressing directly applied to the 
wound; the cavities of the wound and abscesses should be dilated 
and filled with wads of charpie or wadding dipped in a strong anti- 
septic solution. After numerous experiments I always return to 
acetate of lead and alumina ; it is a very active desiccant and deodor- 
ant, without disagreeable odor. It is true, the dirty dark-gray color, 
due to sulphuret of lead from the sulphuretted hydrogen in the 
sanies and the lead in the antiseptic solution, is disagreeable, but it 
is harmless. Till the mortified tissues have been entirely saturated 
with the solution of acetate of alumina and lead, the dressing must 
be frequently changed, or the solution may be poured over the dress- 
ing every two hours. When the wound begins to clean up, one 
dressing daily is enough ; on simple granulating wounds this solution 
is too drying, irritating, and painful ; later we use protective dress- 
ings or salves. Next to acetate of alumina and lead, chloride of lime 



LACERATED WOUNDS. 181 

solution is most active ; but as its effect is due to development of 
chlorine, it is very temporary, and dressings with this substance 
must be frequently renewed to deodorize or disinfect well. Gly- 
cerine is a good disinfectant, and acts excellently if poured freely on 
the dressing every two hours. If applied early, it withdraws so 
much water from the necrosed shreds of tissue that there is no smell ; 
but if decomposition has once begun, its deodorizing effect is very 
slow. After using it freely for three or four days, the wound often 
becomes so red and sensitive that we must refrain from further ap- 
plications. Solutions of chloride of zinc are also recommended for 
washing out purulent cavities ; I have rarely found its superficial 
cauterizing effect very obstinate. Strong solutions of carbolic acid 
in oil or water (five per cent, and over), when applied to large sur- 
faces, not unfrequently cause dangerous symptoms of poisoning, and 
are not so effectual for deodorizing, mummifying necrosed tissues, 
and limiting putrefaction, as acetate of alumina and lead. I have 
no personal experience of the antiseptic properties of salicylic acid 
(recommended by Kolbe and Thiersch), or of sulphite of soda (rec- 
ommended by Polli and Minnich). 

If, however, secondary inflammations attack the wound, they 
should be treated as already advised; retained pus should be removed, 
foreign bodies extracted, etc., then the wound treated with ice, per- 
haps, till all is brought in order again, and the patient free from fever. 

In such cases shall we prescribe any thing for our patients besides 
cooling drinks and medicines, regulating their diet, etc. ? The febris 
remittens not unfrequently accompanying such suppurations renders 
the patient dull, peevish, and often sleepless. Two remedies are 
proper here — quinine and opium ; quinine as a tonic and febrifuge, 
opium as a narcotic, especially in the evening, to secure a night's 
rest. With such patients I usually pursue the following method : 
As long as they are little if at all feverish, I give nothing ; if they 
grow feverish toward evening, in the afternoon I give two doses of 
quinine (five grains each) in solution or powder, and in the evening 
before bedtime from the eighth to half a grain of muriate of morphia, 
or a grain of opium. As soon as the fever ceases, I stop these medi- 
cines ; you must especially avoid liberality with opium, when it is 
not required, for it is constipating. 



Now a few words about lacerated wounds. In general, these are 
less dangerous than contused wounds, because they are more exposed, 
and we have no need to fear that the injury is deeper than we can 
see ; we perceive how the skin, muscles, nerves, and vessels are torn ; 



182 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

healing by first intention may be tried for and succeeds occasionally 
although suppuration generally occurs. But stay, ruptures are not 
always exposed; there are also subcutaneous ruptures of muscles, ten- 
dons, or even of bones, without there having been any contusion. A 
person wishes to leap a ditch, and makes a start, but fails in his at- 
tempt ; he falls, and feels a severe pain in one leg, and limps on it. 
On examination, just above the heel (the tuberositas calcanei), we find 
a depression in which the thumb may be laid ; the motions of the foot 
are imperfect, especially extension. What has happened ? The tendo 
Achillis has been torn from the calcaneus by the great muscular ac- 
tion. The same thing occurs with the tendon of the quadriceps 
femoris, which is attached to the patella, with the patella itself, which 
may be torn in two, with the ligamentum pateihe, with the triceps 
brachii, which may be torn from the olecranon, and generally carries 
a piece of the latter along with it. Here you have a few examples of 
such subcutaneous ruptures of tendons; I have seen subcutaneous 
rupture of the rectus abdominis, of the vastus externis cruris, and 
other muscles. These simple subcutaneous ruptures of muscles are 
not serious injuries ; they are readily recognized by the disturbance of 
function, by the depression, which may be seen and still better felt, 
which at once occurs, but subsequently is masked by the effused blood. 
The treatment is simple : rest of the part, placing it so that the rup- 
tured ends may be brought in contact by relaxation of the muscle, 
cold compresses, lead-water lotions for several days ; after eight or 
ten days the patient can generally rise without pain ; at first there is 
a connective-tissue intermediate substance, which soon condenses so 
much, by shortening and atrophy, that a firm tendinous cicatrix forms; 
the course is just the same as in subcutaneous division of tendons, of 
which we shall speak in the chapter on deformities. 

Functional disturbances of any considerable amount rarely re- 
main ; occasionally there is some weakness of the extremity and loss 
of delicate movements, especially in the hand. 

For such subcutaneous rupture of muscles and tendons to be 
caused by contusion, the crushing force would have to be very great; 
such a contusion would probably run a bad course ; extensive suppu- 
rations and necroses of tendons might be expected. Here, again, you 
see how varied may be the course of injuries apparently the same, 
according to the mode of their origin. In injuries by machinery 
there is often such a wonderful combination of crushing, twisting, and 
lacerating, that even with great experience it is very difficult to give 
any accurate prognosis of their course. The favorable course of cases, 
where small or even large portions of a limb (as the hand) are torn 
off, is especially worthy of mention. I have seen two cases where 



LACERATED WOUNDS. 183 

fingers were torn off; I will briefly narrate one of them: a mason was 
employed on a scaffolding, and suddenly felt it giving way under him; 

Fig. 40. Fro. 41. Fig. 42. 



Central end of 
a torn brach- 
ial artery. 




Torn-out middle finger, with all its Arm torn out, with scapula 
tendons. and clavicle. 



184 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 

from the roof of the house against which the scaffold rested there 
hung a loop; the falling man grasped this, but only succeeded in get- 
ting the middle finger of the right hand through the loop ; he huno- a 
moment and then fell to the ground. Fortunately, the height was not 
great, and he was not injured, but the middle finger of the right hand 
was gone; it was torn out at the joint between the first phalanx and 
the metacarpal bone, and it still hung in the loop. The two tendons 
of the flexors and that of the extensor remained attached to the fin- 
ger ; they had been torn off just at the insertion of the muscles ; the 
man dried his finger with the tendons, and subsequently carried it in 
his purse as a memento of the circumstance. I saw a similar case in 
the clinic at Zurich (Fig. 41). Cure resulted without much inflam- 
mation of the forearm, and actually no treatment was required. In 
Zurich I saw two cases where the hand was torn out ; in one case 
there was enough skin remaining to leave the healing to itself, in the 
other case an amputation of the forearm was necessary. Both cases 
terminated favorably. In war it is not very rare for arms and legs to 
be torn from their sockets by large cannon-balls. I have also seen a 
case where a boy fourteen years old had the right arm with the scap- 
ula and clavicle so torn from the thorax, by a wheel of machinery, 
that it was only attached at the shoulder by a strip of skin two 
inches wide (Fig. 42). The axillary artery did not bleed a drop; 
both ends were closed by torsion (Fig. 40). The unfortunate fellow 
died soon after the injury. Tearing out of entire extremities is usu- 
ally quickly fatal. 



CHAPTER V. 
SIMPLE FB AC TUBES OF BONES. 



LECTURE XIV. 



Causes, Different Varieties of Fractures. — Symptoms, Diagnosis. — Course and External 
Symptoms.— Anatomy of Healing, Formation of Callus. — Source of the Inflamma- 
tory Osseous New Formation. — Histology. 

Gentlemen : Hitherto we have been exclusively occupied with 
injuries of the soft parts ; it is time to consider the bones. You will 
find that the processes that Nature excites for the restoration of the 
parts are essentially the same that you already know ; but the circum- 
stances are more complicated, and can only be fully understood when 
you are perfectly acquainted with the mode of healing in the soft 
parts. Every person knows that bones may be broken, and again be 
firmly united ; this can only be done by bony tissue, as you will at 
once see; hence it follows that new bony substance must be formed ; 
the cicatrix in bone is usually bone ; a very important fact, for, if this 
were not the case, if the broken ends only grew together by connec- 
tive tissue, as divided muscles do, the long bones particularly would 
not be united firmly enough to support the body, and after the sim- 
plest fractures many men would be cripples for life. Still, before fol- 
lowing the process of the healing of bones to its more minute details, 
a study that has always been pursued with great zeal by surgeons, 
I must tell you something about the origin and symptoms of simple 
fractures ; I say " simple or subcutaneous fractures " in contradistinc- 
tion to those accompanied by wounds of the soft parts. 

Man may even come into the world with broken bones : the bones 
of the foetus may be broken, while in the uterus, by abnormal con- 
tractions of that organ, or by blows or kicks on the pregnant abdomen, 
and such intra-uterine fractures generally heal with considerable dislo- 
cation ; as we shall see in other instances, the vis medicatrix natures 



186 SIMPLE FRACTURES OF BONES. 

is a better physician than surgeon. Of course, fractures of the bones 
may occur at any age, but they are most frequent between the ages 
of twenty-five and sixty years, for the following reasons : The bones 
of children are still pliable, and hence do not break so easily ; if a 
child falls, it does not fall heavily. Old people have, as is commonly 
remarked, brittle, friable bones ; or, anatomically expressed, in old age 
the medullary cavity grows larger, the cortical substance thinner ; but 
old persons are less in danger of fractures of the bones, because their 
lack of strength prevents their doing hard and dangerous work. It is 
during the age when men are most exposed to hard work that injuries 
generally and fractures especially are most liable to occur. The less 
frequency of fractures among women is due to the variety of their 
occupation. It is also due entirely to external circumstances that the 
long bones of the extremities, especially of the right side, break more 
frequently than those of the trunk. It is evident that diseased bones, 
which are already weak, break more easily than healthy ones ; hence 
certain diseases of the bones greatly predispose to fractures, especially 
the so-called English disease, " rickets," which is due to deficient de- 
posit of lime-salts in the bones, and only occurs in children; also 
softening of the bones or "osteomalacia," which depends on ab- 
normal dilatation of the medullary cavity, and thinning of the cor- 
tical substance, and which is, to a great extent, accompanied by 
a " fragilitas ossium," and even by total softness and flexibility of the 
bones. 

As special causes of fractures, we have the two following : 1. The 
action of external forces, the most frequent cause ; this action may 
vary in the following ways : the force — for instance, a blow or kick — 
meets the bone directly, so that it is crushed or broken ; or the bone, 
especially a long bone, is bent more than its elasticity permits, and 
breaks like a stick that is bent too much ; here the force acts indi- 
rectly on the point of fracture. In the mechanism of the latter variety, 
instead of the single hollow bone, you may consider a whole extremity 
or the entire spinal column as a stick, flexible to a certain extent, and 
on this supposition found your idea of the indirect action of the force. 
Let us have a couple of examples to explain this : If a heavy body falls 
on a forearm at rest, the bones are broken by direct force ; if a person 
falls on the shoulder, and the clavicle is broken obliquely through the 
middle, this is the result of indirect force. In both cases there is usu- 
ally contusion of the soft parts ; but in the latter case it is more or 
less removed from the point of fracture ; in the former at that point, 
which evidently is to be regarded as less favorable. 7 

2. Muscular action may, though rarely, be the cause of fracture. 
As I already indicated, when speaking of the subcutaneous rupture of 



VARIETIES OF SIMPLE FRACTURES. 187 

muscles, the patella, the olecranon, and part of the calcaneus also, may 
be torn off by muscular action, that is, obliquely fractured. 

The way in which the bones break under these varied applications 
of force varies, but some types have been formed that you should 
know. First, we distinguish complete and incomplete fractures. 
Incomplete fractures are again subdivided into fissures, i. e., clefts, 
cracks ; they are most frequent in the flat bones, but occur also in the 
long bones, especially as longitudinal fissures accompanying other 
fractures ; the cleft may gape or appear simply as a crack in glass. 
Infraction, or bending, is a partial fracture, which, as a rule, only 
occurs in very elastic, soft bones, and especially in rachitic children; 
you may best imitate this fracture by bending a quill till its concave 
side breaks in. In children, such infractions of the clavicle are not 
rare. What we mean by splintering is evident ; the most frequent 
causes are machine-cutters, sabre-strokes, etc. Lastly, the bone may 
be perforated without entire solution of continuity, as by a punctured 
wound through the scapula, or a clean shot through the head of the 
numerus. The latter variety of injury is called a perforated fracture. 

Complete fractures are subdivided into transverse, oblique, longi- 
tudinal, dentate, simple, or multiple fractures of the same bone, com- 
minuted; all of these expressions explain themselves. Lastly, we 
must mention that persons as old as twenty years may also have a 
solution of continuity in the epiphyseal cartilages, although this is rare, 
and the long bones break more readily at some other point. 

Frequently it is easy to recognize that a bone is broken, and a 
non-professional person may make the diagnosis with certainty; in 
other cases the diagnosis may be very difficult, and occasionally can 
only be a probable one. 

Let us take up the symptoms one after another. First, accustom 
yourself to examine every injured part accurately, and compare it 
with healthy parts ; this is particularly important in the extremities. 
You may not unfrequently know what the injury is by simple ob- 
servation of the injured extremity. You ask the patient how it hap- 
pened, having him undressed meantime, or, if this be painful, have his 
clothes cut off, that you may accurately examine the injured part. The 
manner and severity of the injury, the weight of any body that has 
fallen on the part, may indicate about what you have to expect. If 
you find the extremity crooked, the thigh bent outward, for instance, 
and swollen, if suggillations appear under the skin, if the patient can- 
not move the extremity without great pain, you may with certainty 
decide on a fracture ; here you need no further examination to decide 
on the simple fact of a fracture, it is not necessary to put the patient 
to any pain on this account ; you have only to examine with the 



188 SIMPLE FRACTURES OF BONES. 

hands to find how and where the fracture runs ; this is less necessary, 
on account of determining the treatment, than to be able to decide 
whether and how recovery will result. In this case you have made 
the diagnosis at a glance, and in surgical practice it will often be easy 
for you to recognize very quickly the true state of affairs, when you 
are accustomed to use your eyes thoughtfully, and when you have ac- 
quired a certain habit in judging of normal forms of the body. Never- 
theless, you should know perfectly how you arrived at this sudden 
diagnosis. The first point was the mode of the injury, then the de- 
formity ; the latter is caused by two or more pieces of bone (frag 
ments) having been displaced. This dislocation of the fragments is 
due partly to the injury itself (they are driven in the direction that 
they maintain, from the bending of the bone), partly to the muscular 
action which no longer affects the entire bone, but only a part ; the 
muscles are excited to contraction, partly by the pain from the injury, 
partly by the pointed ends of the bone ; for instance, the upper por- 
tion of a fractured thigh-bone is elevated by the flexors, the lower por- 
tion is drawn up near or behind the upper fragment by other muscles, 
and thus the thigh is shortened and deformed. The swelling is caused 
by the effusion of blood (we speak here of a fracture that has just oc- 
curred) ; the blood comes chiefly from the medullary cavity of the 
bone, and also from the vessels of the surrounding soft parts which 
have been crushed or torn by the ends of the bone ; it looks bluish 
through the skin, if it works up to the skin, as it gradually does. The 
patient can only move the extremity with great pain ; the cause of 
this disturbance of function is evident, we need waste no words on 
it. If we examine each of the above symptoms separately, none of 
them, either the mode of injury, the deformity, swelling, effusion of 
blood, or functional disturbance, will alone be evidence of a fracture, 
but the combination is very decisive ; and you will often have to 
make such a diagnosis in practice. But all these symptoms may be 
absent when there is fracture. If there has been an injury, and none 
of the above symptoms are well developed, or only one or other of them 
distinctly exists, manual examination must aid us. What will you 
feel with your hands ? You should learn this thoroughly at once. I 
so often see practitioners feel about the injured part for a long time 
with both hands, causing the patients unspeakable pain, and after all 
finding out nothing by their examination. By the touch you may 
perceive three things in fractures : 1. Abnormal mobility, the only 
pathognomonic sign of fracture ; 2. You may often detect the course 
of the fracture, and often whether there are more than two fragments ; 
3. By moving the fragments you will often experience a rubbing and 
cracking of the fragments against each other, the so-called " crepita- 



SYMPTOMS OF SIMPLE FRACTURES. 189 

tiori* — strictly to crepitate means to crackle ; this is a sound, and still 
We say, we feel crepitation ; it is no use to object to this ; this is an 
abuse of the word, which has so gone into practice, however, that it 
cannot be rooted out, and every one knows what it means. An edu- 
cated touch usually feels at once all that can be detected by the 
touch ; hence it is unnecessary to make the patient suffer long under 
this examination. Crepitation may be absent or very indistinct ; of 
course, it only exists when the fragments can be moved, and when 
they are quite near each other; if they be considerably displaced 
laterally or be drawn far apart by muscular contraction, or if there be 
blood between the fragments, no crepitation can be felt, and it is 
often difficult to detect when the bones lie deep. Hence, if we 
detect no crepitation, this, in opposition to all the other symptoms, 
does not prove that there is no fracture. Still, even where there is crep- 
itation, you may mistake its origin ; you may have a feeling of fric- 
tion under other circumstances ; for instance, the compression of blood 
coagula or fibrinous exudations may give a feeling of crepitation ; 
this soft crepitation, which is analogous to pleuritic friction, you 
should not and will not mistake for bony crepitus after some experi- 
ence in examination ; when opportunity offers, I shall hereafter call 
your attention to other soft friction-sounds which occur especially in 
the shoulder-joint in children and old persons. For experienced sur- 
geons, in certain fractures severe pain at a fixed point is enough for a 
correct diagnosis, especially as in contusions the pain on grasping the 
bone is mostly diffuse, and rarely so severe as in fracture. If we are 
examining an extremity, it is best to seize it with both hands at the 
suspected point, and attempt motion here ; this manipulation should 
be firm, but not rough, of course. I must add something about the 
dislocation of the fragments ; this may vary, but the displacements 
may be divided in various classes, which from time immemorial have 
had certain technical designations, which are still used, and which 
consequently must be explained. Simple lateral displacement is 
called dislocatio ad latus ; if the fragments form an angle like a half- 
broken stick, it is called dislocatio ad axin. If a fragment be rotated 
more or less on its axis, we call it dislocatio ad peripheriam y if the 
broken ends be shoved past each other vertically, it is a dislocatio ad 
longitudinem. The expressions are short and distinctive, and easily 
remembered, especially if you represent to yourselves the displace- 
ments by diagrams. 

We now pass to a description of the course of healing of a frac- 
ture. You will rarely have the opportunity of seeing what happens 
when no bandage is applied, as the patient generally sends early for 
a surgeon. But occasionally the laity undervalue the importance of 



190 SIMPLE FKACTURES OF BONES. 

the injury ; several days pass before the pain and duration of the 
affection at last cause the patient to apply to a surgeon. In such 
cases, besides the symptoms of fracture already given, you find great 
oedema, and in some few cases inflammatory redness of the skin about 
the point of fracture ; under such circumstances the examination may 
be very difficult ; occasionally the swelling is so considerable that an 
exact diagnosis as to the course and variety of the fracture is out of 
the question. Hence the earlier we see a fracture the better. The 
subsequent external changes at the point of fracture may best be 
studied on bones that lie superficially, and which cannot be sur- 
rounded with a bandage, as on fracture of the clavicle. After seven 
to nine days, the inflammatory oedematous swelling of the skin has 
subsided, the extravasated blood has run through its discolorations 
and goes on to reabsorption, and a firm, immovable, hard tumor lies 
around the point of fracture ; this is larger or smaller according to the 
dislocation of the fragments ; it is, as it were, poured around the frag- 
ments, and in the course of eight days becomes as hard as cartilage ; 
this is called callus. Pressure on it (the fragments can with difficulty 
be felt through it) is painful, though less so than previously ; subse- 
quently the callus becomes absolutely firm, the broken ends are no 
longer movable, the fracture may be regarded as healed ; for the clav- 
icle this requires three weeks, in smaller bones a shorter, and in larger 
ones a much longer time. But this does not end the external changes ; 
the callus does not remain as thick as it was ; for months or years 
it grows thinner, and, if there was no dislocation of the fragments, 
after a time no trace of the fracture will remain ; if there was a dis- 
location that could not be reduced by treatment, the ends of the bone 
unite obliquely and after absorption of the callus the bone remains 
crooked. 

To find out the changes that take place in the deeper parts, how 
the fractured ends unite, we try experiments on animals. We make 
artificial fractures on dogs or rabbits, apply a dressing, kill the ani- 
mals at various stages, and then examine the fracture ; we may thus 
obtain a perfect representation of the process. These experiments 
have been made innumerable times. The results have always been 
essentially the same ; but, if we speak of rabbits alone, there are 
certain variations which, as proved by numerous experiments, depend 
on the amount of dislocation and of extravasation of blood. Hence, 
before showing you a series of such preparations, I must give you the 
result of these investigations, and exemplify them by a few diagrams ; 
then you will hereafter readily understand the slight modifications. 

We shall first confine ourselves to what we can see with the naked 
eye and a lens. If you examine a rabbit's leg three or four days after 



FORMATION OF CALLUS. 



191 



the fracture, and, while it is firmly held in a vice, saw the bone longi- 
tudinally, you find the following : the soft parts about the fracture are 
swollen and elastic ; the muscles and subcutaneous cellular tissue look 
fatty ; the swollen soft parts form a spindle-shaped, not very thick 
tumor about the seat of fracture. About the broken ends we find 
some dark extravasated blood, and the medullary cavity at the same 
point is somewhat infiltrated with blood. The amount of this escaped 
blood varies, being sometimes very slight, again considerable. At the 
point of fracture the periosteum may be readily recognized, and is in- 
timately connected with the other swollen soft parts (which are the 
seat of plastic infiltration). Occasionally it is somewhat detached 
from the bone at the point of fracture. The whole thing looks about 
as follows (Fig. 43) : 

Fig. 44. 



Fig. 43. 



..C 



Longitudinal section of a fracture of a 
rabbit's bone, four days old; a, ex- 
travasated blood ; b, swollen soft parts 
external callus ; c, periosteum. 




Diagram of a longitudinal section of a 
fifteen-day-old fracture of a long bone ; 
a, internal callus ; 6, inner, c, outer 
layer of ossification of the external 
callus; d, new periosteum. The di- 
mensions of the callus, in proportion 
to the entire lack of dislocation of 
the fragments, are represented as far 
too great, but this facilitates the pre* 
liminary understanding of the case. 



If we now examine a fracture in a rabbit after ten or twelve days, 
we find that the extravasation has either entirely disappeared, or that 
only a slight amount remains. I will not raise the question as to 
whether it has been entirely reabsorbed, or has partly organized to 
callus. The spindle-shaped swelling of the soft parts has mostly the 
appearance and consistence of cartilage, and has also the same micro- 
scopical characteristics ; in the medullary cavity also we find young 



192 SIMPLE FRACTURES OF BONES. 

cartilage formations in the vicinity of the fracture. The broken bone 
sticks in this cartilage as if the two fragments had been dipped in 
sealing-wax and stuck together ; the periosteum is still tolerably dis- 
tinct in the cartilaginous mass, but it is swollen, and its contours are 
indistinct. Although there are traces of ossification even now, they 
do not become very decided or evident to the naked eye for some days 
(perhaps the fourteenth to the twentieth day after the fracture). 
Then we see the following (Fig. 44) : 

In the vicinity of the fracture there is young soft bone : 1. In the 
medullary cavity (a). 2. Immediately on the cortical layer (£>), and 
some distance up and down beneath the periosteum, which has disap- 
peared in the whole spindle-shaped callus tumor. 3. In the periphery 
of the callus, which is still mostly cartilaginous (c). The periosteum 
which previously lay within the callus has now disappeared ; in its 
place a thickened layer of tissue has formed on the outside of the 
callus, which represents the periosteum (d). The young bone-sub- 
stance is soft, white, and in it we may see a kind of structure ; for 
small parallel pieces of bone, corresponding to the transverse axis of 
the bone, may be distinctly seen, especially on examination with a 
lens. The cartilaginous callus formed from the surrounding soft parts, 
into which the periosteum also has been partly transformed, now 
forms an enclosed whole, and ossifies entirely, partly from without (c), 
partly from within (h), till finally the ends of the bone stick in bony, 
as they previously did in the cartilaginous callus. This bony callus, 
which consists entirely of spongy bone-substance, is called by Du* 
puytren "provisional callus" As it is completed, the bone is 
usually firm enough to be again capable of function ; but the callus 
does not remain in its present condition any more than a recent cica- 
trix of the soft parts does. A series of changes occurs in it in the 
course of months or years, for up to this point you may still compare 
the union to that by sealing-wax, which is not a true organic union. 
So far the firm cortical substance is only united by loose young bone- 
substance ; the medullary cavity is plugged with bone ; the healing 
is not yet solid ; Nature does far more. We shall now study the 
subsequent changes ; they are confined to the spongy substance 
of the callus. At a certain time this ceases to increase, and then 
changes, by reabsorption of the bony substance that has formed in 
the medullary cavity (Fig. 45), and by the disappearance of a great 
part of the external callus. Meantime, formation of new bone has 
commenced between the fractured cortical layers, so that this has 
become solid by the time the external and internal callus disap- 
pears. This connecting bony substance between the fragments grad- 
ually increases in density, to such an extent that it becomes as hard as 




UNION OF FRACTURES. 193 

the bone in the normal cortical substance. In case there has been 
little or no displacement of the fragments, the bone is thus so fully 
restored that we can no longer determine FlG> 45 

the point of fracture, either on the living 
person or the anatomical preparation. 

The above changes occur in a long 
bone of a rabbit, where there has been 
little displacement, in about twenty-six 
or twenty-eight weeks, but in the long 
bones of man last much longer, so far as 
we can judge from preparations that we 
accidentally have the opportunity of ex- 
amining,; 

The entire process, so excellently con- 
trived by Nature, is essentially the same 
as what we observe in the normal devel- 
opment of the long; bones ; for there, too, Longitudinal section of a fractured 

F , ' . , , . . bone from a rabbit, after twenty- 

the same reabsorption and condensation four weeks. Progressive reab- 

. .... ill sorption of the callus. Kestora- 

take place m the medullary canal and the tion of the medullary cavity, 

. . , , „ ., , , natural size ; after Gurlt. 

cortical layers or the long bones, as we 

have just studied in formation of callus. Except the regeneration 
of nerves, no such complete restoration of a destroyed part takes 
place in any other part of the human bodj as we have seen occurs 
in the bones. 

I must still add a few remarks about the healing of flat and spongy 
bones. In the case of the first, which we see most frequently in the 
healing of fissures of the cranial bones, the development of provi- 
sional callus is very slight, and occasionally appears to be entirely 
wanting. In the scapula, where dislocation of small, or half or 
wholly detached fragments is more apt to occur, external callus forms 
more readily, although even here it never becomes very thick. On the 
union of spongy bones, too, in which, as a rule, there is also but little 
dislocation, there is less development of external callus than in the 
long bones ; while, on the other hand, the cavities of the spongy sub- 
stance in the immediate vicinity of the fracture are filled with bony 
substance, of which part, at least, subsequently disappears. 

As may readily be imagined, the conditions will be somewhat 
more complicated when the ends of the bone are much dislocated, or 
when fragments are entirely broken off and displaced. In such cases 
there is such a rich development of callus, partly from the entire sur- 
face of the dislocated fragments and from the medullary cavity, and 
partly in the soft parts between the fragments, that for some distance 
all the fragments are embedded in a bony mass, and organically glued 
13 



194 



SIMPLE FRACTURES OF BONES. 



together. The larger the circle of irritation from the dislocated frag- 
ments, the more extensive the formative reaction. 

In man we most frequently have the opportunity of seeing callus 
formation in greatly dislocated fractures of the clavicle, where it is 
very evident that the extent of the new formation of bony substance 
is directly proportional to the amount of dislocation. You may read- 
ily understand how, in this way, with extensive formation of neo- 
plastic bone-substance, there may be perfect firmness, even with great 
deformity at the point of fracture. Still, one would hardly believe, 
without satisfying himself on the point, from preparations, that with 
time, even in such cases, Nature has the power of restoring, not only 
the outward shape of the bone (except the curvature and rotation), 
but also the medullary cavity, by reabsorption and condensation, 



Fig. 46. 




Fia. 47. 




Fracture of the tibia of a rabbit, with 
great dislocation, with extensive 
formation of callus, after 27 days. 
Natural size, after Skutsch. 
(Gurlfs Fractures, vol. i., p. 270.) 



Old united oblique fracture of a human tibia ; 
the ends of the fragments have been 
rounded off by absorption, the external 
callus reabsorbed ; formation of the me- 
dullary cavity incomplete. Size dimin- 
ished. Gurlt, 1. c, p. 287. 



Numbers of points, nodules, inequalities and roughnesses of all sorts, 
that are formed on the young callus in recent cases, so disappear in 
the course of months and years, that in their place there is only left 
some dense, compact, cortical substance. 



FORMATION OF NEW BONE. 



195 



It will now be interesting to investigate the true origin of the 
newly-formed bony substance ; is it produced by the bone itself, by 
the periosteum, by the surrounding soft parts, or is the extravasated 
blood transformed into bone, as was believed by old observers? 
Must formation of cartilage always precede that of bone, or is this 
unnecessary? These questions have received various answers, till 
quite recently. To the periosteum, especially, great power of pro- 
ducing bone has at one time been ascribed, at another denied. In 
what follows, I will briefly give you the results of my investigations 
on this subject. 

The new formation that results from the fracture occurs in the 
medulla and Haversian canals of the bone, in the periosteum, and in- 
filtrated in the adjacent muscles and tendons ; possibly the extrava- 
sated blood may also have something, but very little, to do with the 
formation of the callus ; a large extravasation is disturbing here, as in 
healing of wounds of the soft parts, for part of it must be organized, 
while the remainder is absorbed. The inflammatory new formation 
here, also, at first consists of small round cells, which increase greatly 
in number, and infiltrate the tissues mentioned, and then almost take 
their place. Before following the fate of this cell-formation further, I 
must briefly consider its course in the Haversian canals. The cell-in- 
filtration in the connective tissue of the medullary cavity offers 
nothing peculiar, except that the fat-cells of the medulla disappear 
in the mass as the wandering cells take possession of the territory. 
Suppose the following figure (Fig. 48) to represent the surface, or the 
fractured surface, of a bone on which, as you know, the Haversian 
canals open; in these canals lie blood-vessels, surrounded by some 
connective tissue. 

If this bony surface be in the vicinity of a fracture, numerous 



Fio. 4a 




Diagram of a longitudinal section through the cortical snhstance of a long bone, o, surface : 
%, Haversian canals, with blood-vessels and connective tissue ; c. periosteum. Magnified 
403 diameters. 



196 SIMPLE FRACTURE OF BONES. 

cells first come between the connective tissue in the Haversian canals ; 
should this cell-infiltration be very rapid, it would entirely compress 
the blood-vessels, and cause the death of the bone, a process which 
we shall hereafter learn. Bat, if the cell-increase in these canals goes 
on slowly, their walls are gradually absorbed, as it would appear, by 
the inflammatory new formation itself; the canals are dilated, the cells 
fill them, and at the same time the blood-vessels increase by forming 
loops. 

From the observations of CoTinheim, we must suppose that in 
inflammation of bone, also, the young cells in the Haversian canals 
are not newly formed, but are white blood-cells escaped from the ves- 
sels. This has no effect on the subsequent course. 

Now, let us turn to the changes of form that we observe in the 
osseous tissue. As the connective tissue of the osseous canals is con- 
tinuous, both with the periosteum and medulla, the cell-infiltration 
into the bone, periosteum, and medulla, is also continuous. The cause 
of the atrophy of bone along the walls of the Haversian canals, 
which takes place in this, as in most other new formations in the bone, 
is difficult to explain; the disappearance of the connective tissue and 
muscular substance, as well as of other soft structures, when the in- 
flammatory new formation occurs in them, is less strange ; but it is 
truly remarkable that hard bony substance should thus be dissolved. 
This process might be represented by the following diagram (Fig. 49) : 

Fie. 49. 




Diagram of inflammatory new formation in the Haversian canals, a, surface ; b 5, Haversian 
canals, dilated, filled with cells and new vessels ; c, periosteum. Magnified 400 diameters. 

You see that the dilatation of the osseous canals is not regular, 
but of uneven widths ; the bone looks as if gnawed out ; this is not 
necessarily so, the atrophy of the bone may be more regular ; accord- 
ing to my idea, these irregularities result from the collection of cells 
in groups, or from looping of the vessels, which press against the 



FORMATION OF CALLUS. 19 7 

bene and cause its atrophy. ~Virchow and others believe that these 
protuberances correspond to the nutrient territory of certain bone- 
cells, which in this process aid in reabsorption of the bone. I think I 
have refuted this, by showing that even dead portions of bone and 
ivory are also affected by the inflammatory new formation ; we shall 
speak more of this when treating of pseudarthrosis. At present it is 
not known how the lime-salts are dissolved in this process ; I think 
orobably the new formation in the bone develops lactic acid, which 
changes the carbonate and phosphate of lime into soluble lactate of 
lime, and that this is taken up and removed by the vessels ; but this 
is only hypothesis. It would also be possible for the organic basis of 
the bone, the so-called osseous cartilage, to be first dissolved by the 
inflammatory neoplasia, and then there would be a breaking-down of 
the chalky substance, whose molecules would be subsequently re- 
moved, even if undissolved. Although I have conversed with many 
chemists and physiologists on this point, none of them have given me 
a simple explanation of this process, nor could they indicate any mode 
of experimenting that might aid in solving the question. 

In the above diagrams, if we suppose the fractured surface where 
there is no periosteum, in place of the surface of the bone, you will 
understand how the new formation (the young callus) grows from it 
out of the Haversian canals as above described, similar neoplasia 
from the other fragment meets and unites with it, as in healing of 
the soft parts. It is evident that the bone through which the inflam- 
matory neoplasia thus grows must become porous, from the reabsorp- 
tion that takes place on the walls of the canal ; if you macerate a 
bone in this stage, till the young neoplasia decomposes, the dry bone 
will appear rough, porous, gnawed, while young bone-substance is 
deposited on it and in its medullary cavity. I must again repeat 
that in drawings and descriptions we have, for the sake of clearness, 
made the callous formation appear much more extensive than it really 
is, and that here, as in wounds of the soft parts, the regenerative 
processes do not usually extend very far or very deep, but are merely 
enough for healing, rarely in excess. In this whole explanation we 
have not mentioned the bone-cells or stellate bone-corpuscles ; I am 
convinced that they have as little to do with these processes as the 
fixed connective-tissue cells, and that the bone-substance, like the soft 
parts, is dissolved by a certain amount of inflammation, and replaced 
by new. 

So far we only know the neoplasia in the state where it consists 
essentially of cells and vessels, as the soft parts do under the same 
circumstances ; if there was retrogression to a connective-tissue cica- 
trix here as there is there, we should h^ye no solid bone formed, but a 



198 



SIMPLE FRACTURE OF BONES. 



connective-tissue union, pseudoarthrosis (from ipevdrjg, false ; apftpuoiq, 
joint), a false joint ; we shall hereafter describe these exceptional cases. 
Under normal circumstances the neoplasia now ossifies, as you already 
know. This ossification may either occur directly or after the inflamma- 
tory neoplasia has been transformed to cartilage. You know that both 
of these modes are seen in normal growth of the bone ; direct ossifica- 
tion of young cell-formation, for instance, in the periosteum of the 
growing bone, or formation of cartilage with subsequent ossification, 
as at first in the entire skeleton and in growth of the bones length- 
wise. Callus from fractures varies greatly in this respect in men and 
animals. In rabbits the callus is always changed to cartilage before 
ossification, as it also is in children. In old dogs the callus usually 
ossifies directly, as in the human adult ; we are far from knowing the 
causes of these differences. To obtain a histological representation 
of these processes, let us return to our former diagram (Fig. 49) ; now 
imagine that the cells, lying in the spaces caused by reabsorption in 
the Haversian canals and surface of the bone, soon ossify and first fill 
these spaces (Fig. 50), then collect on the surface and in the medulla. 

Fig. 50. 




Diagram of ossification of inflammatory neoplasia on the surface of the bone and in the Haver- 
sian canals. Osteoplastic periostitis and ostitis. Magnified 400 diameters. 



and thus form the external and internal callus. Periostitis and 
ostitis, which lead chiefly or exclusively to the. formation of new 
bone, we call osteoplastic ; in the present case the callus is the result 
of this. 



FORMATION OF CALLUS. 



199 



As previously remarked, the periosteum is used up in the neopla- 
sia and in ossifying callus, in its place, externally around the callus, a 
thick connective-tissue layer develops, from which new periosteum 
is formed. I will show you a few more preparations in explanation 

Fig. 51. 




Artificially-injected external callus, of slight thickness, on the surface of a rabbit's tibia, in the 
vicinity of a five-day-old fracture. Longitudinal section— a, callus ; b, bone. Magnified 20 
diameters. 



Fia. 52. 




HP; 



of the process in the periosteum. You see (Fig. 51) the peculiar 
course of the vessels almost at right angles to the bone, which enter 

the bone through the young callus. 
The ossification of the callus begins, 
mantle-like, around these vessels, and 
the little columns which first appear 
in the external callus are thus formed 
(see remarks on Fig. 44). 

You have a good representation of 
the formation of external (periosteal) 
and internal (endosteal) callus in the 
following (incomplete) transverse sec- 
tion of the tibia of a dog, from the 
immediate vicinity of an eight-day- 
old fracture, in which you must also 
observe the vessels of the cortical sub- 
stance, which are considerably dilated 
as compared with normal (Fig. 52). 

Lastly, observe the following prepa- 
ration. It is an eight-day-old, already 
ossified, external callus on the surface 

Artificially-injected transverse s section of Q f ^e tibia of a dog, magnified 250 
the tibia of a dog, from the immedi- °' ° 

ate vicinity of an eight-day-old frac- times (Fip;. 53). 
ture. a, internal callus; 5, external ; \ & / 

cc, cortical layer of the bone. Magni- If we now view the process as a 

fled 20 diameters. r . 

whole, we see that the cell infiltra- 
tion in the bone itself, as well as in all the surrounding parts, aids 
in the formation of callus, and that hence the periosteum plays no ex- 
clusive osteoplastic role. This might have been concluded a priori, 




200 



SIMPLE FRACTURE OF BONES. 



because if the periosteum alone formed the external callus, as was 
formerly supposed, the portions of the bone free of periosteum, as 
those places where tendons are attached to the bone, could form 
no callus ; this is directly contradicted by observation. In normal 
growth, also, the periosteum does not by any means play the im- 
portant part ascribed to it in the formation of bone ; for we may just 
as correctly regard the layer of young cells lying on the surface of 
the bone, and extending into the Haversian canals, as belonging to 
the bone, as to refer it to the periosteum. 




x^mMismi 



Ossifying callus on the surface of a hollow hone, near a fracture. Longitudinal section magnified 800. 
As appears, the ossifying callus is not limited to the periosteum, but extends in between the 
muscles. 



Recent investigations concerning the growth of bones, made by 
J. Wolff, render it very probable that they increase in all directions 
by interstitial deposit of young osseous tissue, and hence that 
growth by apposition through the epiphyseal cartilages and perios- 
teum can no longer be regarded as the sole source of increase in 
length and thickness ; such a mode of growth is placed beyond a 



TREATMENT OF FRACTURES. 201 

doubt by Wegner's excellent work on the osteoplastic action of phos- 
phorus on growing bones. 

I will not conceal from you that the view which I have obstinately 
maintained, that the bone-cells in new osseous formations do not pro- 
liferate, but remain quite passive, is much disputed ; since Cohn- 
heim has shown the passiveness of the stabile connective-tissue cor- 
puscles in inflammation, there does not seem so much strangeness 
about my view, which was advanced years ago, and was founded on 
numerous observations ; still, the explanation of the preparations in 
question is not simple enough to permit only one view. Recently, 
by very careful investigations about the histological changes during 
the transformation of provisional into definitive callus, Lossen has tried 
to show that the bone-cells in the former take an active part in the 
formation of vascular canals in the latter by enlarging and changing 
position. I can agree with this entirely without abandoning the 
above views, for the provision-callus is like the young osteophytes of 
calcified connective tissue, like certain boundary-layers between car- 
tilage and bone. I have no doubt that the cells of this " osteoid car- 
tilage" ( Virchow), like the cells of hyaline cartilage, proliferate to 
true bone. But this is not the place to enter more deeply into the 
histological details, which, great as is their intrinsic interest, have no 
essential influence on the definitive formation of the new development 
of bone. 



LECTURE XV. 

Treatment of Simple Fractures. — Reduction. — Time for applying the Dressing, its 
Choice. — Plaster of Paris and Starch Dressings, Splints, Permanent Extension. — 
Retaining the Limb in Position. — Indications for removing the Dressings 

We shall pass at once to the treatment of simple oi subcutaneous 
fractures, especially fractures of the extremities, for these are by far the 
more frequent, and they particularly require treatment by dressings, 
while those of the head or trunk are to be treated less by dressings 
than by appropriate position, as is taught in the lectures on special 
surgery and in the surgical clinic. 

The indications we have to consider are, simply to remove any 
dislocations and to keep the fractured extremity in the correct ana- 
tomical position till the fracture is healed. 

First, the fragments are to be replaced; sometimes this may 



202 SIMPLE FKACTURE OF BONES. 

be unnecessary, as when there is no dislocation, for instance, in some 
fractures of the ulna, fibula, etc. In other cases it is very difficult, and 
cannot always be done perfectly. The obstacles to the reposition may 
be in the position of the fragments themselves ; one fragment may be 
wedged into another, or a small fragment lies between the chief ones, 
so that the latter cannot be brought together accurately ; fractures 
of the lower articular extremity of the humerus are very obstinate in 
this respect, for small fragments may be so dislocated that neither 
flexion nor extension of the elbow-joint can be performed perfectly ; 
hence its functions remain permanently impaired. Muscular con- 
traction forms a second obstacle to the reposition of the fragments ; 
the patient involuntarily contracts the muscles of the broken limb, 
thus rubs thejragments together or presses them into the soft parts, 
causing severe pain ; this muscular contraction is occasionally almost 
tetanic, so that, even by great force, it is hardly possible to overcome 
the opposition. Indeed, formerly these difficulties were, to some ex- 
tent, insurmountable; and, although attempts were now and then 
made to attain the object by dividing tendons and muscles, it was 
often only possible to attain an imperfect reposition. All these diffi- 
culties were at once removed by the introduction of chloroform as an 
anaesthetic. Now, in all cases where we do not readily succeed in 
reposition, we anaesthetize the patient with chloroform, till his mus- 
cles are perfectly relaxed, and we can then usually place the frag- 
ments in position without difficulty. Some surgeons go so far as to 
use chloroform in almost all cases of fracture, partly for the examina- 
tion, partly for the application of the dressing. This is unnecessary, 
and may even prove very unpleasant, for some persons, especially those 
in the habit of drinking, at a certain stage of the anaesthesia are 
affected with spasmodic contractions of the extremities, so that, in 
spite of being carefully held by strong assistants, they rub the frac- 
tured ends against each other with fearful force, and we must be very 
careful that a sharp fragment does not pierce the skin. This should 
not frighten you from using chloroform in fractures, when it is neces- 
sary, but simply warn you against being too free with it. The meth- 
od of reposition is usually as follows : The fractured part is grasped 
by two strong assistants at the joints above and below the point of 
fracture, and regular, quiet traction employed, while the surgeon 
holds the extremity at the point of fracture, and, by gentle pressure, 
attempts to force the fragments into position. All sudden, impul- 
sive, forced traction is useless, and should be avoided. Here you 
have to notice two technical expressions ; we term the traction on 
the lower part of the extremity, extension, that on the upper part, 
counter-extension. In fractures, these are both made by the hands. 



TREATMENT OF FRACTURES. 203 

while in dislocations we must occasionally resort to different mechan- 
ical appliances. By the above method accurate reposition will only 
be impossible when, from excessive swelling or from peculiarly un- 
favorable dislocation of the fragments, we are unable to correctly 
recognize the variety of the displacement. 

From our present ideas, which are based on a large number of 
observations, the sooner reposition is made after the occurrence of 
the fracture, the better ; we then at once apply the bandage. This 
was not always the belief, but formerly the adjustment of the frac- 
ture and the application of the dressing were delayed till the disappear- 
ance of the swelling, which almost always occurs if a dressing is not 
at once applied. It was feared that under the pressure of the dress- 
ing the extremity might mortify, and the formation of callus would 
be hindered ; with certain cautions in the application of the dress- 
ing, the former may very readily be avoided, and there is little 
truth in the latter belief. Regarding the choice of the dressing also, 
surgeons have of late reached an almost unanimous opinion. It may 
be regarded as a rule, that a solid, firm dressing should be applied as 
early as possible in all cases of simple subcutaneous fractures of the 
extremities y this may be changed altogether two or three times, but 
in many cases does not need renewal. This mode of dressing is 
called the immovable or fixed, in contradistinction to the movable 
dressings, which must be renewed every couple of days, and are 
only provisional dressings. 

There are several varieties of firm dressings, of which the most 
serviceable are the plaster of Paris, starch, and liquid glass. I shall 
first describe the plaster dressing, and show its application, as it is 
the one most frequently used, and answers all requirements in a way 
that can scarcely be improved. 

Plaster of Paris JBandage. — After adjustment of the fragments, 
the broken limb is extended and counter-extended by two assistants, 
then one or more layers of wadding applied over the point of fracture, 
and over parts where the skin lies directly over the bone, as over the 
crest of the tibia, the condyles, and malleoli. Now it is best to en- 
velop the limb with a new fine flannel roller-bandage, so as to make 
regular pressure on it, and cover all parts that are to be surrounded 
by the plaster-bandage. In hospital and poor practice, where we can- 
not always have flannel, we may use soft cotton or gauze bandages. 
Now comes the application of the plaster-bandages prepared for the 
purpose ; the plaster-bandage that I here have is cut from a very thin 
gauze-like stuff; it is prepared by sprinkling finely-powdered plaster 
(modelling plaster) over the unrolled bandage and then rolling it. In 
private practice a number of these bandages of various sizes may be 



204 SIMPLE FRACTURE OF BONES. 

prepared beforehand and kept in a well-closed tin box. Here in the 
hospital, where these plaster-bandages are much used, they are pre- 
pared two or three times a week. This bandage you place in a basin 
of cold water and let it soak through, then apply it like any roller- 
bandage to the extremity prepared as above described. Three or at 
most four thicknesses of this plaster-bandage suffice to give the dress- 
ing the requisite firmness. In about ten minutes good plaster be- 
comes stiff enough for us to lay the extremity loose on the bed ; in 
half an hour or an hour, the dressing becomes as hard as stone and 
quite dry; the time required for hardening depends partly on the 
quality of the plaster, partly on how much you have moistened the 
bandage. After many comparisons with other modes of applying the 
plaster-bandage, I have found this the most practical ; but I must 
mention some modifications of the way of handling the plaster and of 
the material of the bandage. For instance, we may rub the plaster 
into the common muslin or flannel bandages, which makes the dress- 
ing somewhat heavier and firmer ; but this is not necessary and the 
loose gauze is very much cheaper than muslin-bandage. If the band- 
age does not appear sufficiently firm, we may apply a layer of plaster- 
paste over the dressing ; this plaster-paste is to be made with water, 
and spread on the bandage very quickly with the hand or a spoon ; it. 
should not be prepared till we wish to use it, as it stiffens very quick- 
ly. The plaster-dressing as made with roller-bandages was first in- 
troduced by a Dutch surgeon, Mathysen / this method was first pub- 
lished in 1832 ; but it has only become well known since 1850 ; it has 
been spread through Germany chiefly by the Berlin school. A differ- 
ent mode of applying the plaster-dressing is by different strips of 
bandage ; JPirogoff first hit on this method from lack of bandages 
in the army ; all kinds of material were cut into the shape of splints, 
then drawn through thin plaster-paste and laid on the broken limb, 
then the whole was coated with plaster-paste and a firm capsule was 
thus made. Subsequently the same surgeon made a special method 
of this ; he cut old coarse sail-cloth into certain patterns for each limb, 
and applied it in the above manner. Lastly, the so-called many-tailed 
bandage of Scultetus was used in the same way as a plaster-bandage. 
The foundation of the bandage has also been modified in various 
ways ; it has even been used without wadding or any under-bandage, 
the whole limb being simply covered with oil so that the plaster- 
bandage, being applied directly, might not adhere to the skin by the 
fine hairs. Others have employed thick layers of wadding without 
any under-bandage. Lastly, thin wooden splints or strips of tin have 
been lately used in it, as we shall hereafter see ; this may have certain 
advantages in fenestrated bandages. 



TREATMENT OF FRACTURES. 205 

I have intentionally represented all these modifications of the 
plaster-bandage as only exceptionally useful, all of them having cer- 
tain objections as compared with the method first described. A more 
careful criticism of these modifications here would lead us too far. 

For persons unskilled in the matter, the removal of the plaster- 
bandage is quite difficult, but you may see that any of my nurses will 
do it with astonishing quickness. It is simply done as follows : with 
a sharp, strong garden-knife we divide the plaster-bandage, not per- 
pendicularly but rather obliquely, as far as the under-bandage, then 
remove the bandage entire, like a shell ; we may also employ the 
plaster-scissors proposed by Szymanoicsld or those of JBruns. We 
use this capsule in some other cases as a provisional dressing. 

Starch-Bandages. — Before plaster-bandages were known, we had 
in the starch-bandage an excellent material for the immovable dressing. 
The starch-bandage was perfected and introduced chiefly by the Belgi- 
an surgeon Seutin (f 1862) ; it is only during the last twelve years 
that it has given place to the plaster-dressing, but it is still used oc- 
casionally. The application of the wadding and under-bandage is the 
same as in the plaster-dressing, but then we apply splints, cut from 
moderately thick pasteboard and softened in water, to the limb, and fas- 
ten them on with bandages thoroughly soaked in starch-paste ; we now 
apply wooden splints till the dressing has hardened, which at the ordi- 
nary temperature requires about twenty-four hours. Compared to the 
plaster-dressing this has the disadvantage of hardening much more 
slowly ; we may improve this somewhat if we use gutta-percha splints 
instead of pasteboard, these may be softened in hot water, and 
adapted to the extremity. Gutta-percha bands, such as are used in 
factories, are very useful as splints. It cannot be denied that the 
introduction of gutta-percha into surgery is to be regarded as a great 
advantage ; but it is too costly to be used in practice for every simple 
fracture, although thick splints of this material harden even quicker 
than plaster. The dressing with roller-bandages prepared with plas- 
ter is so cheap and firm that it will certainly not be displaced again 
by starch-bandages, now that it has been introduced into practice. 

Instead of plaster, solutions of dextrine, pure white of egg, or 
simple mixture of flour and water, were formerly employed; they 
have all gone out of use, but it is well for you to know the usefulness 
of these substances, which are in every house, and which we may 
well employ as provisional dressings. 

Liquid-glass Dressings. — Instead of starch, we may employ the 
liquid glass of the shops (silicate of potash). On applying the dress- 
ing, we paint this on the muslin-bandages with a large brush, after 
having made a substratum of wadding as above described. The liquid 



206 SIMPLE FKACTURE OF BONES. 

glass dries quicker than starch, but not so soon as plaster, nor does it 
become as hard as the latter ; this dressing does for fractures with no 
tendency to displacement ; if we wish to fix dislocated fragments of bone 
by the liquid-glass dressing, we must strengthen it by applying splints. 

I doubt not the time will soon come when every country physician 
will always keep a few plaster-splints ready prepared ; in spite of 
them, provisional dressings remain useful. These consist of band- 
ages, compresses, and splints, of various materials. You may make 
splints of thin boards, shingles, cigar-boxes, pasteboard, tin, leather, 
firmly-plaited straw, the bark of trees, etc., and, for bandages, must 
often content yourselves with old rags, muslin, torn into strips and 
sewed together; hence, in the practical courses on bandaging, it is 
necessary for you to learn to make use of the most varied materials. 

It is not our intention here to introduce to you every thing that 
may be used in the way of dressing, but I must still speak briefly of 
a few things. As may be readily seen, the object of the splints is to 
make the bone immovable by supporting it firmly on various sides ; 
this may be attained by external, internal, anterior, and posterior, 
narrow wooden splints; we may, however, employ hollow splints, 
so-called gutters. Hollow splints are only good when made of plia- 
ble material, as leather, thin sheet-iron, wire-gauze, etc. ; an absolutely 
stiff, hollow splint would only do for certain persons. Besides these 
mechanical aids, there is another method of keeping broken limbs in 
position, namely, permanent extension. This is particularly indicated 
in cases where there is great tendency to shortening, to dislocatio ad 
longitudinem. Attempts have been made to attain this extension by 
attaching weights by various mechanical contrivances, by continued 
traction made by weights hung to the injured limb, by the double- 
inclined plane, where the weight of the leg is used as the extending 
weight. Since, during the past two years, I have unexpectedly seen 
such excellent effect from permanent extension with weights in pain- 
ful contractions at the hip and knee joints, I am compelled to believe 
that this method may also eventually prove very serviceable for the 
gradual adjustment of dislocated fragments of bone. Among the 
arrangements of this nature with which I am acquainted, V. Dum- 
reieher^s so-called railroad apparatus best fulfils the object of perma- 
nent extension, but it is too costly and complicated to come into 
extensive use in private practice ; it is, doubtless, the intention of the 
inventor to employ it chiefly in cases where the dislocation is difficult 
to overcome. [Dr. Gurdon BucTc's apparatus for fractured thigh is 
about as efficacious and much simpler.] The double-inclined plane, 
represented by a thick roller-cushion applied under the hollow of the 



TREATMENT OF FRACTURES. 207 

knee, may occasionally be employed as a suitable fixation apparatus 
in fracture of the neck of the femur in old persons. 

We must still mention some auxiliary appliances which we have 
to employ to keep the broken limb in good position after it has been 
dressed ; for the upper extremity, in most cases, a simple, properly- 
applied cloth, a mitella, or sling, in which the arm is laid, suffices. 
Patients with fractured arm or forearm may be permitted to go about 
with a plaster-bandage and a sling during the entire treatment, with- 
out interfering with the favorable healing. 

For keeping broken lower extremities in position, there are a 
number of mechanical aids, of which the following are the most 
serviceable : sand-bags, narrow sacks filled with sand, about the length 
of the leg ; these are placed both sides of the firm dressing, so that 
the limb may not move from side to side ; for the same purpose we 
may use long, three-sided pieces of wood, cut prismatically, which are 
laid together, so as to form a gutter. For some cases a sack, loosely 
filled with chaff or oats, is sufficient ; we make a hollow in it length- 
wise, and the leg is to be placed in this. If we desire firmer supports, 
we use fracture-boxes, narrow, long, wooden boxes, open at the upper 
end, so that the leg may be placed in them ; and the sides are 
made to turn down, so that the extremity may be carefully inspected, 
without moving it; the elevation of these fracture -boxes may be 
suited to the convenience of the patient. Lastly, we must mention 
the swing, which is usually made with a gallows, or strong bow, 
that is brought over the foot of. the bed, and to which the limb is 
suspended in any sort of a fracture-box, or hollow splint [or Dr. 
Nathan Smith's anterior splint], so that it may swing about; in 
restless patients especially, this has certain advantages. All these 
apparatuses, which, although more rarely employed than formerly, 
are still occasionally useful, you must learn to apply ; you will have 
opportunity for this in the surgical clinic. Of late we rarely apply 
these apparatuses in the lower extremity, as my former assistant. 
Dr. His, who has brought the application and elegance of the 
plaster-bandage to an extraordinary state of perfection, applies a 
well-padded wooden splint, three or four inches wide, to the under 
side of the leg, making it reach somewhat below the heel and as 
high as the knee, or, in fractures of the thigh, as high as the middle 
of the thigh. The limb lies firmly on this board, if the mattress be not 
too uneven : if we wish to attain still greater firmness, we may lay a 
board the width of the bed over the lower third of the mattress, and on 
this place the limb, with its plaster-dressing and supporting splint. In 
the numerous double fractures of both lower extremities that came to 
the Zurich hospital, this supporting apparatus did excellent service. 



208 SIMPLE FRACTURE OF BONES. 

The old form of plaster-moulds has been recently strongly advo- 
cated again by Dr. M. Muller; we have tried it again, but it bears no 
comparison with the plaster-bandage. 

Sentin tried to increase the advantages of firm dressings by giving 
aids that might enable patients with fractured lower limbs to go 
about to some extent. For instance, a patient with a broken leg 
may have a broad leather strap passing over the shoulder, and buckled 
just above the knee, so that the foot will not touch the floor, and then 
let him go on crutches. But I advise you not to carry these experi- 
ments with your patients too far ; at all events, I only allow my 
patients to make such attempts three weeks after the occurrence of 
the fracture, otherwise oedema readily occurs in the broken limb, and 
some patients are so clumsy in the use of crutches, that they are apt 
to fall, and, although this may only cause slight concussion of the 
limb, it is still injurious. 

Lastly, we have to discuss how long the dressing should be left 
on, and the causes that might induce us to remove it before the cure 
is complete. The decision as to whether a dressing is too tightly 
applied is entirely a matter of experience ; the following symptoms 
must guide the surgeon : If there be swelling of the lower part of 
the limb, as of the toes or fingers, which are usually left exposed, if' 
these parts become bluish red, cold, or even senseless, the dressing 
should be removed at once. If the patient complains of severe pain 
under the dressing, it is well to remove it, even if we can see nothing 
to cause it. In judging of the exhibitions of pain, we should know 
the patients ; some always complain, others are very indolent, and 
show their feelings but little ; however, it is better to reapply the 
bandage several times uselessly than once to neglect its removal at 
the right time. I cannot too strongly urge you always to visit, with- 
in twenty-four hours at most, every patient to whom you apply a fixed 
dressing ; then your patient will certainly not come to grief, as un- 
fortunately too often happens, from the carelessness and laziness of 
his surgeon. A series of cases has been published where, after the 
application of a firm dressing, the affected limb mortified, and re- 
quired amputation ; from these cases it was decided that firm dress- 
ings were always improper, while the fault was chiefly due to the 
surgeon. Just think how little trouble we have in treating fractures 
now, compared to former times, when the splints had to be renewed 
every three or four days ; now you need only apply a dressing once. 
But you must not think you have got rid of all trouble in the appli- 
cation of dressings. The application of the firm dressing requires 
just as much practice, dexterity, and care, as did dressing with 
splints. If you are first called to a fracture when it is two or three 



TKEATMENT OF FRACTURES. 209 

days old, when there is already considerable inflammatory swelling, 
you may even then apply the firm dressing, but must apply it more 
loosely, and with plenty of wadding. This dressing will be too loose, 
and should be renewed in ten or twelve days, when the swelling has 
left the soft parts. It will chiefly depend on the looseness of the 
bandage, and the greater or less tendency to dislocation, when and 
how often the dressing should be removed during the treatment. 
Swelling, if not accompanied by considerable contusion, is no contra- 
indication to a carefully-applied firm bandage ; nor do large or small 
vesicles, full of clear or slightly-bloody serum, present any great ob- 
jection ; such vesicles result not unfrequently from contused fractures 
with extensive rupture of the deep veins, since, from obstruction to 
the flow of venous blood, the serum readily escapes from the capilla- 
ries, and elevates the hard layer of the epidermis into a vesicle; we 
puncture these vesicles with a needle, gently press out the fluid, and 
apply some wadding, and they soon dry up. It is the same with 
slight superficial excoriations of the skin ; we are only rarely obliged 
to remove the dressing and apply another, when new vesicles form, 
as we may know by the pain. 

The length of time that a firm dressing must remain on for the 
different fractures you will learn partly in the clinic, partly from spe- 
cial surgery ; I simply mention here, as the limits, that a finger may 
require a fortnight, a thigh sixty days, or more, for healing. If you 
apply the plaster-dressing immediately after the fracture, dislocation 
having been completely removed, the provisional callus will always 
be less, and hence firmness result later, than where there is some dis- 
location and the dressing is applied later ; but this has no effect on 
the formation of definitive callus, and the actual union of the frac- 
tured ends of the bone. 

14 



CHAPTER VL 
OPEN" FBA CTURES AND S UPP UP A TION OF B ONE. 



Difference between Subcutaneous and Open Fractures in regard to Prognosis. — Vari- 
eties of Cases. — Indications for Primary Amputation. — Secondary Amputation. — 
Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Fragments. 

We shall now pass to complicated or open fractures. 

When we speak simply of complicated fractures^ we usually 
mean only those accompanied by wounds of the skin. Strictly speak- 
ing, this is not exact, because there are other complications, some of 
them much more important than wounds of the skin. If the skull be 
fractured, and part of the brain-substance crushed, or some ribs 
broken and the lung wounded, these are also complicated fractures, 
even though the skin should remain uninjured. But, since in these cases 
the complications themselves are more important for the organism 
than the fracture is, we usually term such cases contusion of the brain, 
or injury of the lung, with fracture of the skull or ribs. But we shall 
not here enter on the subject of injuries of internal organs by frag- 
ments of bone, because very complicated states of disease are occa- 
sionally induced in this way, whose analysis you would not now un- 
derstand. For the present let us limit ourselves to fractures of the 
extremities, accompanied by wounds of the skin, which we shall call 
open fractures, and which will give us trouble enough in their course 
and treatment. 

In speaking of the course of simple contusions without wounds, 
and of contused wounds, I have already shown you how readily reab- 
sorption of extravasated blood and the healing of contused parts go 
on, as long as the process is subcutaneous, but how much the condi- 
tions change if the skin also be destroyed. The chief dangers in such 
cases are, as you may remember, decomposition in the wound, exten- 
sive necrosis of crushed or dead parts, progressive suppuration, and 
accompanying protracted, exhausting fever, while we have scarcely 



PROGNOSIS IN OPEN FRACTURES. 211 

mentioned the severe general diseases, erysipelas, putrid-blood poison- 
ing, pyaemia, tetanus, and delirium tremens. The difference between 
•contusions and contused wounds is even more strongly marked in 
simple and compound fractures, as regards course and prognosis. 
While in many cases we can scarcely call a person with simple frac- 
ture sick (we have not spoken of fever there, for it rarely occurs), and 
under the present convenient treatment such an injury is rather an 
inconvenience than a misfortune, a compound fracture of a large bone 
of an extremity, or sometimes even of a finger, may induce severe, 
and too frequently fatal, disease. But, not to alarm you too much, T 
will at once add that there are many grades of danger even in open 
fractures, and, moreover, that their treatment has been much improved 
of late. 

It is very difficult and important, but not always possible, to make 
a correct prognosis about an open fracture at once. The life or death 
of the patient may occasionally hang on the choice of the treatment 
the first few days, so that we must study this subject more accurately. 
The symptoms of an open fracture are of course essentially the same 
as of the subcutaneous, except that discoloration from extravasated 
blood is often wanting, because at least part of the blood escapes 
through the wound. The fractured ends not infrequently, project from 
the wound, or lie exposed in it, so that a glance may suffice for the 
diagnosis of an open fracture. But this is not enough. "We must do 
our best to ascertain how the fracture was caused, whether by direct 
or indirect force, and how great the force ; if it was accompanied by 
crushing and twisting ; whether arteries and nerves have been torn ; 
if the patient lost much blood, and what is his condition at present. 
There are cases where we can say, at the first glance, healing is im- 
possible ; amputation must be resorted to. When a locomotive has 
run over the knee of an unfortunate railroad hand, when a hand or 
forearm has been caught in the wheels or rollers of machinery, when 
a premature explosion in blasting stone has crushed or torn off a limb, 
or hundred-weights have completely mashed a foot or leg, it is not 
difficult for the surgeon to decide at once on primary amputation, and 
usually in such cases the state of the limb is such that the patients 
also, though with a sad heart, quickly consent to the operation. These 
are not the difficult cases. And in other cases it may be just as easy 
to foretell, with considerable certainty, the probability of a favorable 
cure. For instance, if fracture of the leg from indirect force has fol- 
lowed too great bending of the bone, the broken pointed end of the 
crest of the tibia may puncture and force through the skin ; in such 
a case there is no contusion, but simply a tear through the skin. 
When a pointed body strikes forcibly against a small portion of a 



212 OPEN FRACTURES AND SUPPURATION OF BONE. 

limb, and injures bone and skin, the whole extremity may be greatly 
shaken ; but the extent of the injury is not great, and most of such 
cases terminate favorably under suitable treatment. The question- 
able cases lie between these two extremes. In cases where there 
is some contusion, but only a slight amount evident, and the skin is 
only injured at a small spot, it will be very difficult to decide whether 
healing should be attempted or amputation be resorted to, and the 
peculiarity of the individual case alone can settle the question. Of 
late the tendency is increasing rather to try to preserve the limb in 
these doubtful cases than to amputate one that might possibly have 
been saved. This principle is certainly justified on humane grounds ; 
but it cannot be denied that this conservative surgery may be prac- 
tised at the cost of life, and that we cannot with impunity vary too 
much from the principles of the older surgeons, who generally pre- 
ferred amputation in these doubtful cases. Besides mode of origin 
of the injury, and the amount of accompanying contusion, the impor- 
tance in any given case depends on whether we have to deal with 
deep wounds, with fractured bones lying far down among the muscles, 
or with bones lying near the skin, as the danger of suppuration de- 
pends greatly on the depth and extent of the bone-injury. Thus, an 
open fracture at the anterior part of the leg is of more favorable 
prognosis than a similar injury of the arm or forearm. Open fractures 
of the thigh are the most unfavorable ; indeed, some surgeons always 
amputate for such injuries. Large nerve-trunks are rarely torn in 
fractures, and, when they are, it does not seem to have much effect on 
the cure ; and experiments on animals, as well as observations on 
man, show that bones may unite normally in paralyzed limbs. Injury 
of large venous trunks, as of the femoral vein, causes haemorrhage, 
which may be readily checked by a compressing-bandage, it is true, 
but may prove dangerous when the blood effused between the muscles 
and under the skin begins to decompose. Rupture of the arterial 
trunk of a limb occasionally leads at once to considerable arterial 
haemorrhages ; but this is not a necessary sequence ; for, as previously 
shown, a thrombus quickly forms in the crushed artery, so that we do 
not always have extensive haemorrhage. But, if, from the nature of 
the haemorrhage, we recognize the rupture of an artery, according to 
principles already laid down, we should either attempt to ligate the 
artery at the wound, or else at the point of election. Rupture of the 
femoral artery with fracture of the femur is found by experience to 
be followed by gangrene, and is an imperative indication for ampu- 
tation ; in a corresponding injury of the arm, recovery may result 
or gangrene may follow. In fractures of the forearm or leg, even if 
one or both arteries be ruptured, recovery may take place. Lastly, 



PROGNOSIS m OPEN FRACTURES. 213 

in the question as to whether we shall try for union, or proceed to 
amputation, we must consider how useful the limb can be if union 
results and all unfavorable chances have been overcome. In compli- 
cated fractures of the foot and lower part of the leg this question 
may be particularly important, and it has frequently been necessary 
to amputate a foot because of the change of form and position result- 
ing after union of an open, comminuted fracture, which rendered it 
useless for walking. The same thing is to be considered when, in a 
case of moderately extensive gangrene of the foot, we wish to decide 
if it should be amputated or not. The dead portion of the foot may 
be detached in such an inconvenient shape that the remaining stump 
is neither useful for walking nor for the adaptation of an artificial 
limb. In such cases we should amputate, for all our methods of am- 
putating are designed for the future application of artificial limbs. 

Since the nature of the subject has led us directly to the indica- 
tions for amputation in injuries, I shall at once proceed to the sub- 
ject of secondary amputations. In the question as to whether a 
complicated fracture should be amputated or not, you might readily 
satisfy yourself with the idea that it might be done at any future 
time if the fears of an unfavorable course should be realized. On this 
point attentive observation shows that there are two periods for this 
secondary amputation. The first danger threatens the patient from 
an acute decomposition about the wound and the consequent putrid 
intoxication of the blood. The question as to this danger is settled 
during the first four days ; if it arises, and you then amputate (this 
must be done far above the point of putrefaction), it is just at the most 
unfavorable period for the operation, for you will very rarely succeed 
in saving your patient. Somewhat more favorable, but still unfavor- 
able as compared with primary amputations (those made within the 
first forty-eight hours), are the results of amputations made from the 
eighth to the fourteenth day ; they are particularly unfavorable if the 
symptoms of acute purulent infection, pyaemia, are distinctly present. 
If the patient has survived two or three weeks, and profuse exhaust- 
ing suppuration or other local indication for amputation arise, the 
results are again relatively favorable. When some surgeons have 
asserted that secondary amputations give better results than primary, 
they have almost exclusively considered these later secondary ampu- 
tations. But, if we bear in mind how many patients with open frac- 
tures die during the first three weeks, that is, how few of them live till 
the favorable time for secondary amputations, it seems to me we can 
have no doubt about the decided advantages of primary amputations. 
Up to the present time I have rarely found indications for late second- 
ary amputations. 



214 OPEN FRACTURES AND SUPPURATION OF BONE. 

An open fracture may unite in various ways. The skin- wound, as 
well as the deeper parts, occasionally heals by first intention ; this is the 
most favorable case. Under modern treatment this occurs more fre- 
quently than formerly, although, from the nature of the case, the re- 
quirements for this result are not often present. Far more frequently 
(and this is also favorable) the wound only suppurates superficially, 
and not between and around the ends of the bone, but union of the 
bone takes place as in simple subcutaneous fracture. The cases where 
the wound only affects the skin, and does not communicate with the 
fracture, should not be counted among complicated fractures ; but the 
limits are difficult to trace. 

The process of cure must of course differ greatly from the above, 
if the skin-wound be large, the soft parts greatly contused, so that 
fragments are detached from them ; if the suppuration extends deep 
between the muscles and around the bone, and even into its medullary 
cavity; if the fragments are bathed in pus; if half-loose pieces of 
bone lie about, and longitudinal fissures extend into the bone. The 
activity of the soft parts will remain essentially the same as in subcu- 
taneous fractures, except that in this case the inflammatory new forma- 
tion does not directly become callus, but, after detachment of the 
crushed, necrosed shreds of tissue, granulations and pus are formed, 
the former of which are transformed to ossifying callus. The form of 
the callus will not be much changed, except that, where the open 
suppurating wound exists for a long time, there will be a gap in the 
callus-ring till it is closed by the after-growth of deep ossifying granu- 
lations. Hence the process will terminate far more slowly than in 
subcutaneous fracture, just as healing by suppuration takes longer 
than healing by first intention. 

Now, what becomes of the ends of the fragments which, partly or 
entirely denuded of periosteum, lie in the wound ? What becomes 
of pieces detached from the bone, and only loosely attached to the soft 
parts ? As in the soft parts, so here one of two things may happen, 
according as the ends of the bone are living or dead. In the first and 
most frequent case, granulations grow directly from the surface of the 
bone. In the latter, as in the soft parts, plastic activity in the bone 
occurs on the borders of the living ; interstitial granulations and pus 
form ; the bone melts away ; the dead end of the bone, the sequestrum, 
falls off. The extent to which this process of detachment goes natu- 
rally depends on the extent to which the bone is dead, or, expressed 
more physiologically, on the extent to which the circulation has ceased 
from stoppage of the vessels. This extent may vary greatly : it may 
possibly extend only to the superficial layer of the injured bone : and, 
since the whole process is called necrosis, this superficial detachment 



UNION OF OPEN FRACTURES. 215 

of a plate of bone is termed necrosis superficialis, while that of the 
whole fractured end of the bone may be called necrosis totalis • but 
the latter term is more usual for indicating that the entire diaphysis 
of a long bone, or at least the greater part of it, is detached, and the 
opposite of this is necrosis partialis. The opposite of the above- 
mentioned necrosis superficialis, which is also termed exfoliation, is 
properly necrosis centralis, that is, detachment of an inner portion of 
bone. Necrosis superficialis and necrosis of the broken ends and 
partly-detached fragments of the bone are so often combined with sup- 
purating fractures, of which we have to treat here, that we must treat 
of them in this place. It will at first seem strange to you that vascu- 
lar granulations should spring from the hard, smooth cortical substance 
of a long bone. From what has already been said, it will seem pos- 
sible that, under the influence of this plastic process, the hard osseous 
tissue should be so dissolved that there may be a spontaneous solu- 
tion of continuity between the dead and healthy bone. We shall now 
study more exactly these processes of formation of granulations and 
of suppuration in bone. 

You will remember, from the full description of traumatic suppu- 
ration of the soft parts, that in traumatic inflammation the process 
chiefly depends on free suppuration and extensive formation of new 
vessels, as well as on direct cell-infiltration from the blood, while the 
intercellular substance assumes a gelatinous or fluid consistence. 
Both of these processes can only take place to a slight extent in bone, 
especially in the firm cortical substance of a long bone, because the 
firm osseous substance prevents much dilatation of the capillaries 
which are enclosed in the Haversian canals. I may at once call your 
attention to the fact that, from this slight distensibility of the vessels 
in the osseous canals, portions of bone may more readily die than 
would be the case with the soft parts, because, in case of coagulation 
of blood, even in the smaller vessels, the nutrition can be only imper- 
fectly kept up by collateral circulation. Moreover, the connective 
tissue and the vessels in the Haversian canals may be entirely de- 
stroyed by suppuration, so that necrosis at the ends of the fragments 
will be inevitable. Should a vascular granulation-tissue develop on 
the surface of the bone or in its compact substance, this can only occur 
as previously described, after the osseous substance (lime-salts as well 
as organic matter) has disappeared at the point where the new tissue 
is to appear ; hence there must be solution and atrophy of the bone- 
tissue, just as there are of the soft parts under similar circumstances 
(see Fig. 39). The whole difference appears chiefly in the difference 
of time, for the development of granulations on and in the bone takes 
much longer than in the soft parts. I have already stated that the 



216 OPEN FRACTURES AND SUPPURATION OF BONE. 

same process requires much longer in the tendons and fasciae, which 
have few vessels, than in the connective tissue, muscles, and skin ; in 
the bone it requires even more time than in the tendons. The con- 
stitutional power of the individual, and the consequent so-called 
vitality of the tissues, are also to be taken into consideration. 



LECTURE XYI. 

Development of Osseous Granulations. — Histology. — Detachment of the Sequestrum. — 
Histology. — Osseous New Formation around the Detached Sequestrum. — Callus in 
Suppurating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Con- 
dition. — Fever. — Treatment ; Fenestrated, Closed, Split Dressings. — Antiphlogistic 
Remedies. — Immersion.— Rules about Bone-splinters. — After-Treatment. 

When a denuded portion of bone begins to throw out granula- 
tions on its surface (which in complicated fractures we can only see 
when the ends of the fragments are exposed by a large skin-wound, 
on the interior surface of the leg, for instance), we recognize this with 
the naked eye by the following changes : For the first eight or ten 
days after being denuded of periosteum, the bone mostly preserves its 
pure yellowish color, which, even during the last day of the above 
period, changes toward bright rose-color. If we then examine the 
surface of the bone with a lens, we may notice numbers of very fine 
red points and striae, which a few days later become visible to the 
naked eye also ; these rapidly increase in size, grow in length and 
breadth, till they unite and then present a perfect granulating surface 
which passes immediately into the granulations of the surrounding 
soft parts, and subsequently participates in the cicatrization, so that 
such a cicatrix adheres firmly to the bone. 

If we follow this process in its finer histological details, which 
must be chiefly done experimentally, by aid of injected bones de- 
prived of their lime, we have the following result : If the circulation 
in the bone is maintained near to the surface, there is a rich infiltra- 
tion of cells into the connective tissue accompanying the vessels in 
the Haversian canals ; this tissue grows, with the vascular loops de- 
veloping toward the surface, out of the bone at the points where the 
Haversian canals open externally. The development of this young 
granulation-mass laterally results at the expense of reabsorbed bone. 
If we macerate one of these bones with superficial granulations, its 
surface will appear gnawed and rough ; in the living bone, granulation 
tissue fills the numerous small holes, which all communicate with the 
Haversian canals. The surface of the bone does not, however, remain 



UNION OF OPEN FRACTURES. 



217 



in this state, but, while the osseous granulations on the surface con- 
dense to connective tissue and cicatrize, in the deeper parts they 
ossify quite rapidly, so that at the termination of the process of heal- 
ing the surface of the injured bone does not show a deficiency, but 
appears denser from deposit of new bone. You see that here too the 
circumstances are exactly the same as in subcutaneous development of 
the inflammatory neoplasia. If you look at Fig. 49, and suppose the 
periosteum removed from the surface of the bone, the new formation 
(in this case as granulations) will grow fungous-like out of the Haver- 
sian canals. 

You will understand this better if we now follow more carefully 
the process of detachment of necrosed portions of bone. Let us re- 
turn to what we see with the naked eye, and let us suppose we have 
before us a portion of the parietal bone denuded of soft parts ; then, 
if no granulations, as above described, grow from the bone, we shall 
have the following symptoms : While the surrounding soft parts and 
the portion of bone still covered with periosteum have already pro- 
duced numerous granulations and secrete pus, the dead portion of 
bone remains pure white or becomes gray or even blackish. It re- 
mains some weeks, sometimes two months or more ; most proliferant 
granulations grow around it ; cicatrization has already begun in the 
periphery of the wound, and we cannot decide how the case will ter- 
minate, for in the sixth week the surface of the bone may look just as 
it did the day after injury. Some day we feel the bone and find it 




Detachment of a superficial piece of a flat bone (as of one of the cranial bones), which has been ex- 
posed by an injury and become necrosed. Necrosis superficialis ; a, the granulations arising 1 from 
the living portion of the bone undermine the dead portion, the sequestrum (shaded vertically) ; 
&, the lower side of the sequestrum has been considerably eaten away by the granulations, which 
have perforated it at various points. Diagram, natural size. 



218 



OPEN FRACTURES AND SUPPURATION OF BONE. 



movable ; after a few attempts one blade of the forceps may be intro- 
duced under it and we lift off a thin plate of bone, under which we 
find luxuriant granulations ; the under surface of this plate is very 
rough, as if eaten away. Now healing goes on rapidly. It is often 
long before the cicatrix becomes permanent and solid enough to re- 
sist all injuries, such as pressure and friction, but healing often termi- 
nates favorably. This is the process that we term necrosis superfi- 
cialis or exfoliation of bone. We are already acquainted with this 
process in the soft parts ; during the first week large shreds of tissue 
fall from the contused wound, since on the border of the healthy tis- 
sue there is an interstitial development of granulation, by which the 
tissue is detached ; the process is the same here. In a bone deprived 
of its lime we may readily examine these processes anatomically. The 
inflammatory neoplasia, or granulation tissue, develops on the mar- 
gin of the healthy bone in the Haversian canals. The accompanying 
figure (Fig. 55) may represent to you the details of this process. 

If you have fully understood what has been said, it only requires 
a slight stretch of imagination to see how the same process of detach- 
ment of a fragment may extend through the entire thickness of bone ; 
that is, how (and here we come back to complicated fractures) a vari- 
able length of the fractured end of a bone may be entirely detached^ 
when it is incapable of living. 
When the bone in question is 
thick, this process requires sev- 
eral months; but at last we 
may find even large pieces of 
bone movable in the wound, and 
remove them as we would a su- 
perficial bony plate. 

As regards splinters entirely 
detached from the bone, and only 
attached to the soft parts, their 
future fate, as regards living or 
not, depends on how far their 
circulation is preserved. If they 
are not capable of living, they 
at last become entirely detach- 
ed by suppuration of the soft 
parts attached to them, and of- 
ten, as foreign bodies, keep up 
irritation and suppuration of the 
wound. If they are capable of 
living, they produce granula- 




Diagram of detachment of a necrosed portion of 
bone. Magnified 300. a, necrosed portion of 
bone; ft, living bone; c, new formation in the 
Haversian canals, by which the bone is de- 
tached. Compare Fig. 36. 



DETACHMENT OF THE SEQUESTRUM. 



219 



tions on the free surface ; these subsequently ossify and unite with the 
other callus, forming around the fractured ends. 

To represent the relation of the formation of callus to this process 
of detachment of the necrosed ends of the fractured bone, I present 
the following figure (Fig. 56). 

The fragments of the broken bone are not accurately adjusted, 
but displaced somewhat laterally ; the ends of the fragments have 
both become necrosed, and nearly detached by interstitial proliferation 
of granulations on the borders of the living bone. The whole wound 
is lined with granulations, which secrete pus that escapes at d. In 
both fragments, an inner callus (b b) has formed, which, however, from 
suppuration of the fractured surfaces, has not yet been soldered to- 
gether. The outer callus (c c) is irregular, and interrupted at d, be- 
cause the pus escapes here from the first. When the granulations 
grow so strongly as to fill the entire cavity, and subsequently ossify, 
healing is completed, and the final result is just the same as in the 
healing of subcutaneous fractures. For this to take place the necrosed 
portions of bone must be removed, for experience shows they cannot 
heal up in the osseous cicatrix. This elimination of the sequestrated 



Fig. 56. 



Fig. 57. 




Diagram of fracture of a long bone with 
external wound, longitudinal section. 
Natural size, ee, bone; ////, soft parts 
of the limb ; aaaa, necrosed ends of 
bone. The darkly-shaded part repre- 
sents the granulations, which line (d) 
the wound that opens outwardly, and 
secrete pus ; bb, internal callus in the 
two dislocated ends of bone; cc exter 
nal callus. 




Amputation stump of 
the thigh, with necro- 
sis of the sawed sur- 
face. 



220 OPEN FRACTURES AND SUPPURATION OF BONE. 

fragments takes place either by reabsorption or by artificial removal 
outwardly ; the former is the more frequent in small, the latter in 
large sequestra ; but union will not result as long as the sequestrum 
remains between the granulations of the fragments. Since the open- 
ing at d may be much contracted by the development of external 
callus, the operative removal of the necrosed ends is often very diffi- 
cult. We find, by examination with the probe, whether such seques- 
tra in the deeper parts really existed, and if they are detached. If 
you suppose the sequestrum, a a (Fig. 56), removed from the wound, 
there is no obstacle to the filling of the wound with granulations and 
to their subsequent ossification. Such sequestra in complicated frac- 
tures are frequently the cause, not only of new exacerbations of the 
acute suppurative inflammation, but also of subacute and chronic peri- 
ostitis, with protracted firm oedema of the extremity and annoying 
eczematous eruptions on the skin, as well as of long-continued bone 
fistulae and ulcerations of the ends of the fragment. The action of 
this sequestrum combines the double effect of a foreign body and 
that of local or general purulent infection. 

We may speak here of conditions as they exist in the bone after 
amputation. Imagine Fig. 56 divided transversely at the point of 
fracture and the lower half removed, then the condition will be just 
the same as after amputation. Granulations either grow directly 
from the wounded surface, or a portion (the sawed surface) is necrosed 
to a greater or less extent (Fig. 57). Let this be as it may, in the 
medullary cavity, as well as on the outside of the bone, a neoplasia 
(a half callus) is formed ; this subsequently ossifies ; if you examine an 
amputation stump several months old, you will find the medullary 
space in the stump of the bone closed by osseous deposits, as well as 
external thickening of the bone. We may here remark that the name 
callus is used almost exclusively for the bony new formation in frac- 
tures, while the young bony formations on the outside occurring in 
various ways are called " osteophytes " (from dareov, bone, and (pyfia, 
tumor) ; callus and osteophytes are not then very different, but both 
are designations for young osseous formations. 



In considering the process of suppuration, we have left out of con- 
sideration two of the constituents of bone, namely, the periosteum and 
medulla. In observing the development of callus, we saw that the 
periosteum also had something to do with the formation of new bone. 
But, if, in open suppurating fractures, the suppurative inflammation 
spreads greatly as a result of extensive contusion, a large amount of 



SUPPURATIVE PERIOSTITIS. 221 

periosteum may necrose or suppurate, and in such cases we find 
wide-spread suppurative periostitis / the greater part of a long bone, 
as the tibia, may be bathed in pus. The bone thus losing its connec- 
tion with the soft parts, its supply of blood is withdrawn, and from 
this cause there may be extensive necrosis of the bone as a result of 
suppurative periostitis. But these local dangers are slight in com- 
parison to the dangers to the organism at large from these deep sup- 
purations ; we shall hereafter treat fully of these. 

In the same way the medulla either of a long or spongy bone may 
participate in the suppuration. From what has already been said, you 
know that, in the course of the normal union of fracture, new bone- 
tissue forms in the medullary cavity, and closes it for some time. In 
open, suppurating fractures there is also occasionally suppuration of 
the medulla, that may extend more or less. Such a suppurative os- 
teomyelitis is quite as dangerous, both for the life of the bone and for 
the entire organism, as suppurative periostitis. From various causes, 
too, it may asssume a putrid character ; the larger veins of the bone, 
that come from the medulla, may participate in the suppuration, and 
this disease is the more destructive because of its deep situation ; it is 
often first recognized at the autopsy. Purulent osteomyelitis alone 
may also lead to partial and even to total necrosis of a bone, the more 
so when combined with suppurative periostitis. 

Although it was necessary to make you acquainted with all the 
above local complications of open fractures, I may say for your relief 
that they rarely occur so extensively as above described ; neither total 
necrosis of both ends of the fracture, nor extensive purulent perios- 
titis and osteomyelitis are frequent results of these fractures ; but, for- 
tunately, healing of the deeper parts often takes place very simply, 
and suppuration only continues externally. 

Whether a traumatic inflammation leading to suppuration shall 
extend beyond the borders of the irritation (of the injury) depends, as 
in simple contused wounds, on the grade of the local infection by 
mortifying tissue in the wound, and later on all the circumstances 
that we have learned as direct or indirect causes of secondary in- 
flammation of wounds. The greater the shattering of the bone (espe- 
cially in gunshot- wounds), the greater are all mediate and immediate 
results of the injury. 

Now a few words about the general condition of the patient, espe- 
cially as to fever. While in subcutaneous fractures it is to be regarded 
as a rarity for a patient to have fever, the reverse is true in open frac- 
ture. If ever the fever evidently depends on the extent and intensity of 
the local process, it does so here. As we have already mentioned, in con- 
tused wounds, every extension of the inflammation is accompanied by 



222 OPEN FRACTURES AND SUPPURATION OF BONE. 

an increase of fever, and, generally speaking, this is the more decided 
the deeper the suppuration. In accidental osteomyelitis and perios- 
titis the evening temperature of the body not unfrequently rises above 
one hundred and four degrees Fahrenheit ; rapid elevation of tem- 
perature with chills is, unfortunately, a frequent symptom ; septicaemia 
and pyemia, trismus, and delirium potatorum, are especially apt to 
accompany suppurating fractures, so that I can only repeat here, 
what I said at the beginning of the chapter, that any open fracture 
may be or may become a severe and dangerous injury. Hence, the 
greatest circumspection and care are necessary. I can tell you, from 
my own experience, that the most successful operation never gave me 
such pleasure as the successful union of a severe complicated fracture. 
Let us now pass to the treatment of open fractures. After the 
advantages of firm dressings had become apparent, it was natural to 
try them in modified forms in open fractures ; indeed, some time since, 
jSeutin, the inventor of the starch-bandage, used the so-called fenes- 
trated bandage, i. e., in the firm starch-bandage he made an opening 
corresponding to the wound in the soft parts, so as to leave the latter 
open to observation during treatment. The primitive forms of these 
fenestrated starch and plaster bandages also, which are now often used, 
had great objections, that may now be considered as overcome. The 
chief objection to the fenestrated bandage was that the under-band- 
age and the wadding were readily saturated with pus, which decom- 
posed and became offensive. Extensive experience has shown me 
that these objections may be overcome ; it is only necessary to make 
the openings large enough, to round off the edges with strips of 
muslin attached by plaster, to make the dressing firm by means of 
His's position-splints, by introducing strips of wood, etc., and to catch 
the secretion from the wound in basins placed beneath. If this dress- 
ing remain firm and clean, the trouble of its first application is 
well repaid, not only by the brilliant success of this mode of treat- 
ment, but also by the great saving of time in the subsequent care of 
the wound. For some time I employed plaster-bandages in open 
fractures in this way : at first I applied them closed, just as in simple 
fractures, and soon slit them up lengthwise, opened them, and dressed 
the wound every day or two as required, without moving the frag- 
ments, and continued this till the wound was healed, then applied a 
new closed bandage. This method is good for some cases, and shows 
some good results. The essential thing in these dressings is that, 
after deciding not to amputate, even the most complicated fractures 
should be placed in the plaster-dressing immediately after the injury, 
just as in the case of simple fracture, only with the difference that 
the wound should first be covered with charpie or compresses previ- 
ously dipped in lead-water or solution of chloride of lime, and that 



TREATMENT OF OPEN FRACTURES. 223 

quantities of wadding (two finger-breadths thick) should be laid on 
the limb before the dressing is applied, so that, even if there should 
be swelling, the limb may not be strangulated by the dressing. 

The difficulty of applying any firm dressing is increased by the 
presence of a large wound or of several wounds at the same time. 
Should there be extensive and deep suppuration in such cases, so that 
numerous counter-openings must be made, and the number of the 
wounds thus increased, it will be impossible to keep the same dress- 
ing long, and we may then be obliged temporarily to return to splints 
and fracture-boxes, which must be completely renewed every day. 
Moreover, as you may gather from what has been said, these severe 
cases often stand on the borders of amputation, i. e., their union is 
very problematical. The more practice one has in the application of 
the plaster-dressing, the more rarely will bad accidents happen. 
Since I have applied the dressing in the above manner to complicated 
fractures, I see diffuse septic inflammations and secondary suppura- 
tions much more rarely. I am convinced that the treatment of open 
fractures by plaster-dressings is the best ; but this method must be 
studied, we must not suppose we know it a priori. 

Should a surgeon of the old school see our present treatment of 
fractures, simple as well as complicated, he would consider it not only 
irrational but foolhardy, for formerly fractures, like all other injuries, 
were treated first by antiphlogistics, every thing else being secondary. 
Hence it was considered necessary to apply leeches to the limb in the 
vicinity of the fracture, to keep on cold compresses or bladders of ice, 
and to purge the patient freely. Subsequently, when suppuration 
from the open fracture began, they usually resorted to cataplasms, 
which were continued till healing was almost completed. Besides 
this, splints were applied and changed about every two or three days, 
according as the wound was dressed more or less frequently on ac- 
count of the suppuration. Larrey was one of the first to speak 
against this frequent change of dressings in wounds, especially in open 
fractures ; if we may trust his notes, he carried this idea to an unjus- 
tifiable extent, for he did not always remove the dressings even when 
quantities of maggots had developed under them. Of late, the gen- 
eral opinion is that, in the treatment of open as well as of simple frac- 
tures, the accurate fixation of the fragments is the first requirement for 
favorable union, and that nothing is more apt to excite inflammation 
around the wound than movement of the fragments. Hence a firm 
dressing is the most important and efficacious antiphlogistic that we 
can use. We here repeat a previous remark, that cold and abstrac- 
tion of blood have no prophylactic and antiphlogistic action, as was for- 
merly supposed. If, on account of commencing progressive inflamma- 



224 OPEN FRACTURES AND SUPPURATION OF BONE. 

fcion around the wound, I consider it necessary to apply ice, I remove 
a piece from the plaster-dressing, corresponding to the point where 
the ice-bladder is to be applied. In case of suppuration about the 
wound, openings are to be made for the escape of pus. The general 
principles as to the choice of the point for the opening is to make the 
counter-opening where fluctuation is most distinct, and where the soft 
parts are thinnest, where the pus will escape most readily without 
pressure from the finger. If we have to cut openings in the bandage, 
this may be done most easily two or three hours after its application. 
After making openings in the plaster-bandage corresponding to the 
wound, without disturbing the limb, we separate the wadding, remove 
the charpie, and bind the opening carefully ; then with a spatula we 
introduce wadding under the edges of the opening to prevent the 
secretion from the wound getting under the dressing. For more 
than a year I have been leaving these wounds open also, and have 
been astonished at the success of this method of treatment. In the 
treatment of complicated fractures with plaster-dressings, very care* 
ful manipulation and the knowledge of a large number of details 
which can only be acquired at the bedside of the patient, are neces- 
sary ; the gift of inventing modifications of various forms of dressing 
is also necessary. The treatment of open fractures is often very diffi- 
cult ; every one employs in practice the method he has learned ; it 
makes little difference whether we employ plaster, starch, or liquid- 
glass dressings; the essential thing is for the fragments to lie quiet 
and firm, and not to be moved by the dressings, then the patient will 
recover well and without pain. The favorable experience of immer- 
sion in contused wounds of the hand and foot has induced some sur- 
geons to treat complicated fractures, of the leg and forearm at least, 
in the same way. In the Berlin surgical clinic they have tried keep- 
ing the fractured limb dressed with a fenestrated plaster-bandage, in 
a permanent water-bath ; for this purpose the plaster must be made 
water-tight with cement, solution of shellac, liquid glass, collodium, or 
something of that sort. The results of this treatment are celebrated. 
But, should any suppurative inflammation occur about the wound, in 
which the water-bath is injurious, this method would appear to me 
less suitable than any other. 

In the treatment of open fractures with splints, we generally use 
straight, narrow wooden splints ; in the lower extremity these are pro- 
vided with a suitable foot-piece. 

As we commenced speaking of the treatment of complicated frac- 
tures by describing the dressings, I must add a few words about the 
first examination. The diagnosis of complicated fractures is made 
like that of simple fractures. Passing the fingers into the wound is 



TREATMENT OF OPEN FRACTURES. 225 

usually unnecessary and injurious ; we should only draw out splinters 
of bone when we think we feel or see them entirely loose ; the less 
you examine the wound the better. We leave all adherent splinters 
of bone ; sawing off pointed ends of fragments (primary resection of 
the fragments) I consider unnecessary and generally injurious ; I have 
only done it when, even under chloroform, they projected so that it 
was impossible to replace and keep them in position. The reposition 
of the fragments should be accurately made before the application of 
the dressing ; subsequent bending and traction should be decidedly 
avoided, and, if it should be necessary on account of great dislocation, 
should be postponed till healing of the wound. In the same way 
early traction on half-detached splinters of bone is entirely inappro- 
priate and useless ; a piece of dead bone adherent to the periosteum 
or other soft parts is gradually detached spontaneously, and may then 
be removed. We should not examine till quite late, when the wound 
is fistulous, to see if fragments situated deeply are necrosed, and 
should then do it very carefully and with very clean instruments. If 
there be extensive necrosis of one or both fractured ends, their ex- 
traction may be very difficult ; we then resort to the same operations 
as for necrosis from any cause ; we shall speak of this when treating 
of diseases of the bones, but this should not be done till the process 
has become chronic. 

The union of complicated fractures always requires longer than in 
simple fractures ; indeed, in protracted suppurations it may take double 
the time. We have to decide this by manual examination, and not 
allow the patient to attempt walking till the fracture is perfectly con- 
solidated. The disappearance of the callus, its condensation, its atro- 
phy externally and its reabsorption till the medullary cavity is re- 
stored, go on just as in simple subcutaneous fractures. The treat- 
ment of complicated fractures is one of the most difficult things in 
surgery ; we never cease learning on this point. 

15 



APPENDIX TO CHAPTERS V. AND VI. 

LECTURE XVII. 

1. Eetarded Formation of Callus and Development of Pseudarthrosis. — Causes often 
unknown. — Local Causes. — Constitutional Causes. — Anatomical Conditions. — 
Treatment: internal, operative; Criticism of Methods. 2. Obliquely-united 
Fractures ; Eebreaking, Bloody Operations. — Abnormal Development of Callus. 

1.— EETAEDED DEVELOPMENT OF CALLUS AND FOEMATION OF A SO- 
CALLED FALSE JOINT— A SO-CALLED PSEUDAETHEOSIS. 

Under some circumstances, which we do not always sufficiently 
understand, a fracture is not consolidated after the lapse of the usual 
time ; indeed, it may not consolidate at all, but the seat of fracture 
may remain painless and movable, which of course impairs the func- 
tion of the limb, even to the point of entire uselessness. A short 
time since, a strong farmer-boy, with simple subcutaneous fracture of 
the leg without dislocation, entered the hospital ; as usual, a plaster- 
bandage was applied and renewed in fourteen days. Six weeks after 
the fracture the dressing was removed altogether, in the expectation 
that union had taken place ; but the point of fracture was still per- 
fectly movable, nor could any callus be felt. I here tried the sim- 
plest remedy in such cases, I narcotized the patient, and then rubbed 
the fragments strongly together till crepitation could be distinctly 
perceived ; then I applied another plaster-dressing, and on removing 
this in four weeks found the fracture tolerably firm. I placed the pa- 
tient in a fracture-box, and, without placing any bandage on the leg, 
had its anterior surface painted daily with strong tincture of iodine. 
After this had been continued a fortnight, the fracture was perfectly 
firm ; the patient now stood with the aid of crutches, and in a short 
time was dismissed cured. I know of two other cases from the prac- 
tice of colleagues, where simple fractures in very healthy young per- 
sons did not consolidate, but formed pseudarthroses. Such occur- 
rences are to be regarded as very rare ; usually there is some peculiar 



PSEUDARTHROSIS. 227 

cause, such as disease of the bone, that induces false joint. There are 
certain fractures of the human skeleton which from various causes 
very rarely unite by bony callus ; among these, are intracapsular frac- 
tures of the neck of the femur, neck of the humerus, and fractures of 
the olecranon and patella. When fractured transversely the two latter 
bones separate so far that the osseous substance formed on the two 
ends cannot meet, so that only a ligamentous union can take place be- 
tween these two parts of bone. When fractured within the capsule 
the head of the femur has, it is true, a supply of blood through a 
small artery which enters it through the ligamentum teres, but this 
source of nutrition is very slight, consequently the production of bone 
from the small fragments is slight. In fracture of the head of the 
humerus within the capsule, in the rare case of part of the head be- 
ing entirely detached from the rest of the bone, this portion of bone 
will receive no supply of blood, and will act as a foreign body ; its 
union can scarcely be expected. In the above examples, we regard 
non-union so much as the rule that we do not usually call them cases 
of pseudarthrosis. But I wish to show you that there may be purely 
local causes that predispose to pseudarthrosis; among these espe- 
cially belongs complete loss of large pieces of bone, after the removal 
of which, in open fractures, there may be so large a defect that it will 
not be again filled by new bone-tissue. Protracted suppuration with 
ulcerative destruction, and extensive detachment of the ends of the 
fragments, may also lead to pseudarthrosis. Moreover, the treatment 
is occasionally blamed ; too loose a dressing, or none at all, and too 
early motion, are occasionally accused. On the other hand, it has 
been asserted that too continued application of cold, the simultaneous 
ligation of large arteries, and, lastly, too tight a dressing, may inter- 
fere with proper development of bony callus. All this alone does not 
necessarily lead to pseudarthrosis, but may act as a second cause when 
the general conditions of nutrition in the organism predispose to it. 
Of the general predispositions and bone diseases, the following may 
be mentioned as disposing to pseudarthrosis : bad nutrition, debility 
from repeated losses of blood, specific diseases of the blood, such as 
scorbutis, or cancerous cachexia. Of the diseases of the bones, it is 
chiefly osteomalacia, atrophy of the cortical substance, with enlarge- 
ment of the medullary cavity, in which, as already mentioned, in certain 
stages there is not only decided fragilitas ossium, but in which also the 
chances for reunion are slight. I have stated all this, because it is gen- 
erally accepted, although, on sharp critical examination, some of the 
above-mentioned predisposing causes for pseudarthrosis are of very 
different value, while the significance of others is entirely doubtful. 
In the same way it is a common belief that fractures are not consoK- 



228 APPENDIX TO CHAPTERS V. AND VI. 

dated in pregnant females. This is not true in all cases ; I have my- 
self seen numerous fractures unite in pregnant women, only once 
hardening of the callus was delayed a few weeks in a fracture of the 
lower end of the radius, which was recognized late, as might also 
occur in women not pregnant, or in men. 

The abnormity of the healing process in case of pseudarthrosis is 
not due to the non-formation of callus, but to the failure of ossifica- 
tion in the new formation. The substance connecting the fragments 
becomes a more or less rigid connective tissue, by which the ends of 
the bone are held more or less closely together. If the fragments lie 
so close that they come in contact on motion of the limb, a cavity 
with smooth walls, filled with sero-mucous fluid, forms between them 
in the uniting tissue ; and, on the fractured ends, cartilage has been 
found, so that there was, in fact, a sort of new joint. This does not, 
however, occur very often, but in most cases we have simply a firm 
connecting mass, which sinks directly into the fragments like a 
tendon. When such a pseudarthrosis is in a small bone, such as the 
clavicle, or one of the bones of the forearm, the disturbance of func- 
tion is always bearable ; but, if it be located in the arm, thigh, or 
leg, of course there must be considerable impairment of function. 
In some cases it is possible, by suitable supporting apparatus, to give 
the limb the necessary firmness ; in other cases we cannot do this at 
all, or only incompletely, so that for a long time attempts have been 
made to cure this disease by operation, that is, by inducing ossifica- 
tion. Before passing to the methods used for this purpose, we must 
mention the attempts made to prevent false joint, and to cure it, when 
once established, by internal remedies. Preparations of lime are 
chiefly used for this purpose. Phosphate of lime was given internally 
in the shape of powder ; lime-water was given in milk, but without 
much benefit. Of the lime given in this way, little is absorbed, and, 
of this superfluous lime taken into the blood, much was excreted 
through the kidneys, so that the pseudarthrosis had little good from 
it. We may expect more from general regulation of diet, and pre- 
scribing articles of food that contain lime. Residence in pure country 
air, and milk-diet, are to be recommended ; but you must not expect 
too much from these remedies, especially in a fully-formed false joint 
that has existed for years. In a recently-published and very interest- 
ing work by Wegner, it is shown, by a number of experiments, that 
by continued administration of small doses of phosphorus the forma- 
tion cf callus about fractures is particularly luxurious and hard, as well 
as that in growing animals the portion of bone formed during the ad- 
ministration of phosphorus is unusually dense and hard, and very 
rich in chalky salts. These experiments would lead us to try phos- 



PSEUDARTHROSIS. 229 

phorus in patients with pseudarthrosis, especially in the earlier 
stages ; of course, we should be very careful of this remedy, which 
may be so dangerous when carelessly used. The local remedies all 
aim at inducing inflammation in the ends of the bone and parts 
around, because experience shows that most inflammations in the 
bone, especially subcutaneous traumatic ones, induce formation of 
bone in their immediate vicinity. The remedies employed vary very 
greatly. We have already mentioned the proposals to leave the 
limb without dressing, so as to avoid interfering with the formation 
of the external callus by pressure, also the rubbing together of the 
fragments, and painting with iodine ; with the same view (viz., of 
irritating the fragments), we may apply blisters and the hot iron to 
the part of the limb corresponding to the fracture. By the following 
remedies we act more on the intermediate ligamentous tissue : long, 
thin acupuncture-needles are passed into the ligamentous band, and 
left there for a few days to excite irritation ; we may connect the 
ends of two of these needles with the poles of a galvanic battery, and 
pass an electrical current as an irritant. This proceeding is called elec- 
tro-puncture y it is little used. "We may also pass a thin, small tape, or 
several threads of silk (a so-called seton or a strong ligature), through 
the ligamentous tissue, and leave it there till there is free suppuration 
around it. The following operations attack the bone more directly ; 
they are quite numerous : For instance, a narrow but strong knife is 
passed as deep as the fracture, and the ligamentous tissue is shaved 
first from the end of one fragment, then from the ether, without en- 
larging the skin-wound. This is called the subcutaneous bloody fresh- 
ening of the fragments. Or we may make an incision down to the 
bone, dissect out the two fragments, perforate them close to the fract- 
ured end, and pass a sufficiently thick lead wire through the perfora- 
tions, twist the ends together, so as to approximate the fragments, or 
else, after making an incision, we may saw off a thin piece from each 
fragment, and treat the resulting wound like an open fracture ; and to 
this operatioo, resection of the fragments, we may add the application 
of a suture of the bone. The following operation originates with Dief- 
fenbach : Corresponding to the ends of the fragments he makes two 
small incisions down to the bone, then he perforates the ends of the 
bone close to its borders, and with a hammer drives ivory pegs, of 
suitable thickness, into the perforations. The consequence is, a for- 
mation around these foreign bodies of new bone, which, when ex- 
tensive enough, as it may always be made in the course of time by 
repeating the operation, causes firm union. I will here mention that, 
when extracted in a few weeks, these ivory pegs look rough and 



230 APPENDIX TO CHAPTERS V. AND VI. 

corroded at the points where they were in contact with the bone, 
while the perforation in which they lay is mostly filled with granula- 
tions ; occasionally the pegs are not removed ; the openings through 
which they were introduced heal. This proves absolutely that dead 
bone, among which ivory is to be classed, may be dissolved and reab- 
sorbed by the growing osseous granulations. We shall hereafter have 
frequent occasion to return to this much-contested question, which is 
very important in some bone-diseases ; we have already spoken of 
the theoretical causes of this reabsorption (p. 197). B. v. Langen- 
beck has modified this operation of Dieffenbach by using metal 
screws instead of ivory pegs; immediately after the operation he 
fastens these screws to an apparatus, which keeps the fragments im- 
movable. After all these operations, a suitable dressing must be 
applied to keep the fragments firm. 

The modes of operation in pseudarthrosis, of which I have only 
mentioned the principal ones, are, as you see, quite numerous; and, if 
the results of treatment corresponded to the number of remedies, this 
would belong to the most curable class of diseases. But in medicine 
you may generally take it that, with the increase in number of reme- 
dies for a disease, their value decreases. Easy and certain as some 
forms of pseudarthosis are to cure, others are just as difficult ; nor are 
all the different methods suited to the same case. In the first place, 
the operations vary greatly as to danger, being much more dangerous 
in limbs with thick soft parts, especially in the thigh, than in others ; 
and, as may be readily supposed, the non-bloody operations are less 
dangerous than the bloody ; those made with a small wound less so 
than those with larger. As regards efficacy and certainty, I consider 
the introduction of a bone suture and resection as those which, even 
in the worst cases, give proportionately the quickest results, but 
which still have all the elements of danger of a fracture complicated 
by a wound. The treatment with ivory pegs is less dangerous, ex- 
cept in the thigh, where every false joint is dangerous, and I think it 
would accomplish the object in most cases, if the operation were 
repeated often enough. I have seen good results from this treat- 
ment, and from Von LangenbecJc's screw apparatus, as well as from 
the bone suture. 

In pseudarthrosis of the thigh the question may seriously be 
asked, if we should not prefer amputation at the point of the false 
joint (which is of favorable prognosis) to any other dangerous or 
doubtful operation. This question only the peculiarities of the in- 
dividual case can decide. In some cases the safe aid of a suitable 
splint apparatus, made by a skilful instrument-maker, is preferable to 
any operation. 



OBLIQUELY-UNITED FRACTURES. 231 

2.— OBLIQUELY-UNITED FRACTURES. 

Although, with the progress made in the treatment of fractures, it 
is now rare for union to occur in so oblique a direction as to render 
the limb entirely useless, still, cases from time to time arise where, 
in spite of the greatest care of the surgeon, in fractures with open 
wounds, dislocation cannot be avoided, or else, from carelessness or 
great restlessness of the patient and loose application of the dress- 
ings, a considerable obliquity in the position of the fracture remains. 
In many cases this is so slight that the patients do not care to get 
rid of the deformity; improvement of the position would only be 
desired in cases where, from considerable obliquity or shortening of a 
foot or leg, the movements are decidedly impaired. There are vari- 
ous means by which we may greatly improve or entirely get rid of 
these deformities. If, during the process of union, we notice that the 
fragments are not exactly coapted, we may undertake the adjustment 
at any time in simple subcutaneous fractures. If, in an open fracture, 
obliquity of the fragments has taken place under the first dressing, I 
strongly urge you not to try to rectify it before the wound has healed ; 
you would thus break up the deeper granulations, and the severest 
inflammation might again be excited. In fractures that have long 
suppurated, the callus long remains soft, so that you may always sub- 
sequently accomplish a gradual improvement in position by properly 
padding the splints first in one place, then in another, or perhaps by 
continued extension with weights. If the fracture be fully consoli- 
dated in an oblique position, we have the following remedies for its 
improvement : 

1; Correction by bending the callus, by infraction ; for this pur- 
pose we anaesthetize the patient, and with the hands attempt to bend 
the limb at the point of fracture ; if we succeed in so doing, we apply 
a firm dressing with the limb in the improved position. This method, 
so free from danger, can only be successful while the callus is still soft 
enough to be bent ; hence it can only be done soon after the fracture. 

2. Complete breaking up of the ossified callus. This also may 
sometimes be done by the hands alone, but frequently other mechan- 
ical means will have to be resorted to. For this purpose various ap- 
paratuses have been constructed, such as lever and screw machines of 
considerable power ; one of the most terrible bears the name of " dys- 
morphosteopalinklastes." All these apparatuses should only be used 
with the greatest care, so as not to cause too much bruising and con- 
sequent necrosis of the skin at the point where the machine is applied 
on which the limb rests. For the not unfrequent obliquely-united 
fractures of the thigh, the forced extension of A. Wagner (by the 



232 APPENDIX TO CHAPTERS V. AND VI. 

apparatus of Schneider and Menel, which we also employ for reduc- 
ing old dislocations) has been resorted to with success. The follow- 
ing illustration will fully explain the mechanical effect of this exten- 
sion : If you have a bent rod, and let a strong man take hold of each 
end and draw, the rod will break at the point where it is bent most. 
If a new fracture of the thigh has been caused by indirect force at the 
bent part, and the fragments be adjusted in a straight position, you 
apply a plaster-dressing at once while the limb is still held in the ma- 
chine. As far as our present experience goes, this method appears to 
be entirely free from danger, but only suited for the thigh ; in a case 
of very angular union of a fracture of the leg, where I advised this 
treatment, the break caused by the extension was not in the old seat 
of fracture, but near it. 

3. The bloody operations on the bone, of which there are two in 
use, are more dangerous ; the first of these is the subcutaneous oste- 
otomy of B. v. Langenbeck. This consists in making a small incis- 
ion down to the bone at the bent part, introducing a medium-sized 
gimlet through this opening and perforating the bone, without, how- 
ever, piercing the soft parts on the opposite side ; then draw out the 
perforator, and pass a small, fine saw through the perforation, and saw 
the bone transversely, first to one side, then to the other, till you can 
break the rest of the bone with your hand ; now the bone is to be 
straightened and the injury treated as a complicated fracture. This 
operation has only been done on the leg, but, so far as I know, always 
with good result. It may also be done by not making the adjust- 
ment till suppuration begins, and the callus has thus been softened 
and partly reabsorbed. For V, LangenbecJc's instruments we may 
advantageously substitute fine chisels, as recommended by Gross, for 
dividing the callus from a small exposed portion of the bone. 

4. Lastly, we may employ the method of Mhea Barton, which 
consists in exposing the bone by a large incision through the skin at 
the point of curvature, and sawing out a wedge-shaped piece in such 
a way that the broad part of the wedge shall correspond to the con- 
vexity, the point to the concavity of the abnormal curvature of the 
bone. This method also shows good results. 

On the whole, the non-bloody are to be preferred to the bloody 
methods, if they do not cause too much contusion ; but the latter are 
less dangerous than breaking up fractures with strongly-contusing 
apparatuses. 

If the deformity, especially of a foot, be so great, in different 
directions, that none of the above methods offer much prospect of cure, 
we may have to resort to amputation in some cases. 



OPERATIONS FOR PSEUDARTHROSIS. 233 

In some few cases the callus is abnormally thick and extensive, 
just as happens in cicatrices of the skin and nerves. Do not be too 
hasty about operating in such cases, for slow subsequent reabsorption 
usually takes place in every callus. The removal of such callus masses 
could only be effected with chisel or saw, and I should be unwilling 
to decide on such an operation. 



CHAPTER VII. 
INJURIES OF THE JOINTS. 

Contusion. — Distortion. — Opening of the Joint, and Acute Traumatic Articular Inflam- 
mation. — Variety of Course, and Kesults. — Treatment. — Anatomical Changes. 

Hitherto we have studied injuries of simple tissue-elements; now 
we must occupy ourselves with more complicated apparatuses. 

As is well known, the joints are composed of two ends of bones 
covered with cartilage ; of a sac frequently containing many appen- 
dages, pockets, and bulgings ; the synovial membrane, which is classed 
among the serous membranes ; and of the fibrous capsule of the joint 
with its strengthening ligaments. Under some circumstances, all 
these parts participate in the diseases of the joint, so that at the same 
time we may have disease of a serous membrane, of a fibrous capsule, 
as well as of cartilage and bone. The participation of these different 
parts varies exceedingly in intensity and extent ; but I may state at 
once that the synovial membrane plays the most important part, and 
that the peculiarity of joint-diseases is chiefly due to the closed and 
irregular form of the synovial sac. 

First, a few words about crushing and contusion of the joint. If 
one receives a heavy blow against the joint, it may swell moderately ; 
but in most cases, after a few days of rest and applications of lead- 
water or simple cold water, the swelling and pain subside, and the 
functions of the joint are restored. In other cases, slight pain and 
stiffness remain ; a chronic inflammation develops, which may lead to 
serious disease, of which we cannot at present speak more fully. If 
we have a chance to examine a moderately-contused joint, the patient 
having died perhaps of a serious injury received at the same time, we 
shall find extravasations of blood in the synovial membrane, and even 
blood in the cavity of the joint itself; in these contusions without 
fracture the effusions of blood are rarely so extensive that the joint is 
tensely filled with blood; but this may occur. This condition is 
called hcemarthron (from al\m, blood, and apdpov, joint). If a joint 
that has swollen greatly just after an injury remains painful for some 



OPENINGS OF THE JOINTS. 235 

time, and feels hot, a somewhat more active antiphlogistic treatment 
is indicated. This consists in the application of leeches, regular en- 
velopment of the joint in wet bandages, causing moderate compres- 
sion, and in applying an ice-bladder to the joint. As a rule, inflam- 
mation of this grade may be readily relieved, although chronic dis- 
eases and a certain irritability of the joint that has been injured not 
unfrequently follow. It is very important to determine whether the 
crushing of the joint be accompanied by fracture or fissure of the end 
of the bone, in which case, it would be necessary to apply a plaster- 
dressing, and give a guarded prognosis as to the future usefulness of 
the joint. If the continued application of cold increases the pain, 
make inunctions of mercurial ointment, and apply moist, warm com- 
presses covered with gutta-percha and wadding. 

A form of injury peculiar to joints is distortion (literally, twist- 
ing). This is an injury that occurs especially often in the foot, and 
which is commonly called " turning the foot." Such a distortion, 
which is possible in almost any joint, consists essentially in a tension, 
too great stretching and even partial rupture, of the capsular liga- 
ments, with escape of some blood into the joint and surrounding tis- 
sue. The injury may be very painful at the time, and its consequences 
are not unfrequently tedious, especially if the treatment be not 
rightly conducted. Usually abstraction of blood and cold are resorted 
to in these cases also, but with only temporary benefit. It is much 
more important to keep the joint perfectly motionless after such in- 
juries, so that, if any of the ligaments be ruptured, they may heal and 
acquire their previous firmness. The simplest way of attaining this 
object is by applying a firm dressing, such as the plaster-bandage, 
with which we may permit the patient to go about, if it gives him no 
pain. After ten, twelve, or fourteen days, according to the severity 
of the injury, we may remove the dressing, but renew it at once if the 
patient has pain on walking. It may sometimes be necessary to wear 
this dressing three or four weeks. This appears a long time for such 
an injury ; but I can assure you that, without the application of a firm 
dressing, the consequences of these sprains often continue for months, 
at the same time the danger of subsequent chronic inflammation of 
the joint is increased. Hence you must not promise too speedy a cure, 
and must always treat these, often apparently insignificant injuries, 
conscientiously and carefully. 8 

OPENINGS OF THE JOINTS, AND ACUTE TRAUMATIC ARTICULAR 
INFLAMMATIONS. 

In now passing to wounds of the joint, we make an immense 
spring as regards the importance of the injury. While a contusion 



236 INJURIES OF THE JOINTS. 

and sprain of the joint are scarcely noticed by many patients, the open- 
ing of a synovial sac, with escape of synovia, even if the wound be 
not large, always has a serious effect on the function of the joint, and 
is not unfrequently dangerous to life. Here, again, we have the differ- 
ence between subcutaneous traumatic inflammations and those which 
open outwardly, of which we spoke when on the subject of con- 
tusions, and which we also saw in subcutaneous and open fractures. 
Moreover, in the joints, we have closed irregularly-shaped sacs, in 
which the pus, once formed, remains, and, besides inflammation of the 
serous membranes, may result in very tedious processes, but in its 
acute state often has a bad effect on the general health of the patient. 
I think the quickest way to describe the process will be to give 
you a few examples. "We are here speaking only of simple punctured, 
incised, or cut wounds, without complications from sprains or frac- 
tures, and choose as our example the knee-joint ; at the same time we 
must remark that injuries of this joint are regarded as the most se- 
vere. A man comes to you, who, in cutting wood, has received a 
wound half an inch long, near the patella, and which has bled but 
little. This may have happened some hours before, or even the pre- 
vious day. The patient pays little attention to the wound, and only 
asks your advice about a proper dressing. You inspect the wound, 
find that from its position it corresponds to the knee-joint, and around 
it you may perhaps see some serous, thin, mucous, clear fluid, which 
escapes in greater quantities when the joint is moved. This will call 
your attention particularly to the injury ; you examine the patient, 
and learn from him that, immediately after the injury, there was not 
much bleeding, but a fluid like white of egg escaped. In such cases 
you may be certain that the joint has been opened, otherwise the 
synovia could not have escaped. In small joints the escape of 
synovia is so slight as to be scarcely noticeable, hence, in injuries of 
the finger-joint, and even of the ankle, elbow, and wrist, it may for a 
time be doubtful whether the wound has penetrated the joint or not. 
When a penetrating wound of the joint is certain, the following rules 
should at once be pursued : The patient should keep quiet in bed, 
the wound should be united as quickly as possible, to prevent the es- 
cape of more synovia, which would interfere with healing of the 
wound by first intention ; hence we close the skin-wound, if it has a 
tendency to gape. This may best be done by sutures accurately applied ; 
in some small wounds, carefully-applied adhesive plaster, or ichthyo- 
colla-plaster, painted with collodion, may suffice. Now the joint is to 
be kept absolutely quiet ; this can only be done by firmly bandaging 
the limb, from below, with wet bandages. In the case before us, 
the whole leg should be kept securely and firmly extended on a hoi- 



OPENINGS OF THE JOINTS. 237 

low splint, or between two sacs of sand. If, besides this, you give 
some internal remedy, such as a mild purgative, I think enough has 
been done for the time. In most text-books on surgery, it is true, you 
will find the advice to put on a number of leeches, and to keep a 
bladder of ice constantly applied, to prevent too much inflammation. 
But I can assure you that local abstraction of blood and cold do not 
even here have this prophylactic, antiphlogistic action, and that it is 
time enough to resort to ice in a later stage, although I will not blame 
any one for using ice from the first in inflammation of the joint. The 
above dressing I have of late replaced by the plaster-dressing ; I apply 
it as for a fracture of the knee-joint, from the foot to above the mid- 
dle of the thigh, with a position-splint, then cut an opening corre- 
sponding to the anterior surface of the knee and the wound ; the results 
of this treatment, as compared to the old regular antiphlogistic treat- 
ment, are very brilliant. Let us return to our patient. You will find 
that, on the third or fourth day, he will complain somewhat of burning 
pain in the joint, and be slightly feverish ; on applying your hand, 
the joint feels warmer than the healthy one. When you have re- 
moved the sutures, on the fifth or sixth day, in the following two days 
the course may be in one of two very different directions. Let us 
first take the favorable case, which is frequent under early treatment 
with firm dressings ; the wound will heal entirely by first intention, 
the slight swelling and pain in the joint will diminish during the fol- 
lowing days, and finally disappear entirely. If you remove the dress- 
ing in from four to six weeks, the joint will be again movable ; the 
recovery is complete. 

But in other cases, especially where the patient comes under 
treatment late, things turn out worse. Toward the end of the first 
week there are not only great swelling and heat in the joint, but there 
is oedema of the leg ; the patient has severe pain on being touched, 
as well as on every attempt at motion ; toward evening he has high 
fever, he loses his appetite, and begins to emaciate. At this time the 
wound may be closed, or a sero-mucous and subsequently purulent 
fluid escapes from it. But even if this be not the case, the above symp- 
toms, especially the swelling of the joint, with distinct fluctuation, the 
pain, increased temperature, oedema of the leg, the increase of fever, 
point to an acute, intense inflammation of the joint. If in such cases 
the limb be not fixed, it gradually assumes a flexed position, which in 
the knee-joint may increase to an acute angle. It is not easy to give 
the reason for this flexed position of inflamed joints ; it seems to me 
most probable that it arises, in a reflex manner, by a transfer of the 
irritation of the sensible nerves of the inflamed synovia to the motor 
nerves of the flexor muscles. Another explanation is, that every 



238 INJURIES OF THE JOINTS. 

joint may contain more fluid in the flexed than in the extended posi- 
tion, which has been proved experimentally by Bonnet, who usually 
brought the joints in the cadaver to a flexed position, by injecting fluid 
into them. But these experiments do not seem to me to prove any 
thing about the above-mentioned flexed position, for these also occur 
in articular inflammations where there is no fluid in the joint ; on the 
other hand, they are often absent where there is a great deal of fluid. 
Observation shows that acute painful synovitis most disposes to 
flexion of the joint. 

If the above symptoms have presented themselves, antiphlogistic 
remedies assume their historic value, but we must not forget that at 
the same time the position of the limb should not be neglected, so 
that if absolute stiffness of the joint should occur, this may result in 
the position relatively most favorable for its usefulness, that is, in the 
knee-joint fully extended, in the foot and elbow at a right angle, etc. 
If attention to this point was neglected at the commencement of the 
treatment, you should repair the error by anaesthetizing the patient, 
so that you may, without difficulty, give the limb the proper position. 
Among the antiphlogistic remedies, I attach most importance to pla- 
cing one or more ice-bladders on the inflamed joint, and painting it 
with concentrated tincture of iodine, which should be used till a con- 
siderable extent of epidermis is elevated into a vesicle. 

If the fluid in the joint increases very rapidly, and the tension 
becomes insupportable, and if there is no free escape for the pus 
through the wound, so that there is danger of ulceration of the cap- 
sule from within, and of the pus flowing from the joint into the cel- 
lular tissue, we may carefully draw off the pus with a trocar, of 
course guarding against the entrance of air into the joint. This tap- 
ping of the joint, which of late has been specially recommended by 
JR. Vblkmann, I formerly used with good results, and by it cured, as 
I believe, four successive cases of severe, acute, traumatic inflamma- 
tion of the knee-joint, with perfect restoration of mobility. Since I 
have applied the plaster-bandage in simple penetrating wounds of 
the joint also, I have not resorted to tapping. If the patient is kept 
awake at night by pain, he should have a dose of morphine in the 
evening, and antiphlogistic diet and cooling drinks during the day. 
By this treatment we may succeed in cutting short the acuteness of 
the disease, even in this stage ; but even then the function of the 
joint may not be fully restored, although this is possible in case the 
suppuration of the synovial membrane remams chiefly superficial 
(catarrhal). Frequently, however, the disease passes from an acute 
to a chronic course, the suppuration attacks the tissue more deeply, 
then after recovery there remains more or less stiffness. 



TRAUMATIC ARTICULAR INFLAMMATION. 239 

But, unfortunately, the inflammation in and around the joint occa- 
sionally extends uncontrollably. And, finally, the only thing to be 
done is to enlarge the wound, to make new openings in various 
places ; we then have complete suppuration and destruction of the 
synovial sac. All the communicating synovial sacs do not partici- 
pate equally in the suppuration ; on tapping, you may at one part of 
the joint evacuate serum, at another, pus ; this is probably because 
the swollen synovial membrane closes, like a valve, the openings of 
communication, which are often narrow between the cavity of the 
joint and the adjacent sacs. In bad cases the suppuration extends 
to the soft parts of the thigh and leg, the patient is thus exhausted 
more and more as he also is by severe fever and chills, his cheeks sink, 
and we hesitate about our treatment. Recovery is possible, even in 
this stage ; the acute suppurations gradually cease, and the disease 
becomes chronic, and after several months may terminate in complete 
stiffness of the joint. In many cases we strive in vain to keep up 
the strength of the patient with tonics and strengthening remedies, 
but he dies of exhaustion as a result of new suppurations which 
even occur at points having no connection with the wound. This 
unfortunate termination we can only prevent by amputaion; this 
remedy which is so deplorable, but which in these cases frequently 
saves life. The difficulty here lies in the choice of the proper time for 
operating. Observations at the bedside, which you will make in the 
clinic, must teach you how much you may trust the strength of your 
patient in individual cases, so that you may determine when the last 
moment for the operation has come. In hospital, you will always 
see many such cases die of purulent infection (pysemia), with or 
without amputation. 

Since, in describing traumatic articular inflammation, we held to 
the presentation of a special case, and let the treatment follow the 
symptoms, we must add a few remarks about the pathological anat- 
omy, as it has been accurately studied on the cadaver, on amputated 
limbs, and by aid of experiments. The disease affects chiefly, and at 
first exclusively, the synovial membrane. If this has not been accu- 
rately observed, as I know from my own experience, we are apt to 
consider it too thin and delicate. But, by examining a knee-joint, 
you may readily satisfy yourselves that at most points it is thicker 
and more succulent than the pleura and peritonaeum, and is separated 
from the fibrous articular capsule by a loose subserous cellular tissue, 
which sometimes contains much fat, so that you may detach the syno- 
vial sac of a knee joint from the cartilage as an independent mem- 
brane. As is well known, it consists of connective tissue, has on its 
surface pavement epithelium, and contains a considerable capillary net- 



240 INJURIES OF THE JOINTS. 

work near its surface. We have the investigations of Hueter, about the 
lymphatic vessels of the synovial membrane ; according to them this 
membrane itself contains no lymphatics, while the subsynovial tissue 
is said to be very rich in them. This result is surprising, and hence 
requires repetition with all the aids of modern anatomical art. Since 
the synovial sacs are serous membranes, it is most probable that they 
contain lymphatic vessels, such as have been described in the perito- 
naeum and other serous membranes, by Von Recklinghausen, forming 
superficial nets covered with epithelium, and partly opening on the 
surface of the membrane. The surface of the synovial membrane, es- 
pecially at the sides of the joint, shows a number of tufted processes ; 
these have well-formed and often complicated capillary nets. Syno- 
vial membranes share with other serous membranes the peculiarity of 
secreting a considerable quantity of serum on being irritated. At 
the same time the vessels become dilated and begin to grow tortuous 
toward the surface, the membrane loses its lustre and smoothness, and 
first grows cloudy yellowish-red, and later more red and velvety on 
the surface. In most cases of acute inflammation a more or less 
thick fibrous deposit forms on this surface, a so-called pseudo-mem- 
brane, like that in inflammation of the pleura and peritonaeum. Mi- 
croscopical examination of the synovial membrane in this state shows 
that its entire tissue is greatly infiltrated with plastic matter, and that 
on the surface the collection of cells is so considerable that the tissue 
here consists almost exclusively of small, round cells, of which the 
more superficial have the characteristics of pus-cells ; in the immedi- 
ate vicinity of the greatly-dilated vessels we find the collection of 
wandering cells particularly great, which is probably because in acute 
synovitis numerous white blood-cells wander through the walls of the 
vessels into the tissue, and collect in the vicinity of the vessels ; in 
this process red blood-corpuscles seem also to escape from the vessels 
in great quantities. The pseudo-membranes are composed entirely of 
small, round cells, held together by coagulated fibrine, of whose origin 
from fibrogenous and fibrino-plastic substance we have already spoken 
(p. 63). The connective tissue of the membrane has partly lost its 
striated character, and has a gelatinous mucous consistency, so that it 
greatly resembles the intercellular substance of granulation-tissue; 
in the fluid in the joint, which is constantly becoming more cloudy and 
puruloid, there are at first a few pus-corpuscles, which constantly in- 
crease in number till the fluid has all the characteristics of pus. Still 
later the surface of the synovial membrane is so vascular that even to 
the naked eye it looks like a spongy, slightly-nodular granulation- 
surface, on which pus is constantly forming, as on an ordinary granu- 
lating surface. The condition into which the synovial membrane 



SUPPURATIONS OF JOINTS. 241 

passes, in the first stages, most resembles acute catarrh of the mucous 
membranes. As long as there has been only superficial suppuration 
without disintegration of tissue (without ulceration), the membrane 
may return to the normal state ; but, if the irritation be sufficient not 
only for the formation of pseudo-membrane (which may also be again 
disintegrated), but to cause suppuration of the synovial membrane it- 
self, the only result will be formation of cicatrix. In describing a 
typical case of suppuration of the knee-joint, we have already shown 
that the pus perforates from the knee-joint into the subcutaneous cel- 
lular tissue ; this undoubtedly occurs, but periarticular subcutaneous 
suppurations, after penetrating wounds of joints, also occur occa- 
sionally without depending on perforations of pus; we see them 
both in acute and chronic suppurations of joints, without being able 
to detect a direct communication with the cavity of the joint. From 
my experiments on the phlogistic action of pus, I think this must be 
due to the reabsorption of quickly-formed poisonous pus by the lym- 
phatic vessels of the synovial membrane, and its conduction to the 
periarticular cellular tissue ; at the same time the neighboring lym- 
phatic glands are always swollen. When treating of lymphangitis, 
we shall have to return to this subject. The cartilage does not par- 
ticipate in the inflammation for some time; its surface becomes 
cloudy, and, when the process is very acute, it begins to disintegrate 
to fine molecules, or even to become necrosed in large fragments, and 
to be detached from the bone by the occurrence of inflammation and 
suppuration between cartilage and bone (subchondral ostitis). Al- 
though the cartilage with its cells is not wholly inactive in these 
inflammations — for, from various observations, we can scarcely avoid 
believing that the cartilage-cells may also produce pus — still, I consider 
this state of the cartilage is essentially a passive softening, a sort of 
maceration such as occurs under like circumstances in the cornea when 
there is severe blennorrhea of the conjunctiva. Indeed, there are 
scarcely two parts of the human body so analogous in their relations 
as the conjunctiva in its relations to the cornea, and the synovial 
membrane in its relations to the cartilage. We shall frequently have 
occasion to return to this point, and shall here cease the considera- 
tions, which we shall resume more particularly hereafter. If the acute 
process becomes chronic, and a stiff joint results, an anchylosis (from 
ay/cvXr), bent), it always occurs in the same way in all suppurative 
inflammations of the joints. We shall investigate this more exactly 
when treating of chronic articular inflammations. 

16 



242 INJURIES OF THE JOINTS. 



LECTURE XVIII. 

Simple Dislocations ; Traumatic, Congenital, Pathological Luxations, Subluxations. — 
Etiology.— Difficulties in Eeduction, Treatment; Eeduction, After-Treatment.— 
Habitual Luxations. — Old Luxations, Treatment. — Complicated Luxations. — Con- 
genital Luxations. 

SIMPLE DISLOCATIONS. 

By a dislocation (luxatio), we understand that condition of a 
joint in which the two articular ends are entirely, or for the most part, 
thrown out of their mutual relations, the articular capsule being gen- 
erally partly ruptured at the same time ; at least, this is almost always 
the case in traumatic luxations, i. e., in those that have occurred in a 
healthy joint as a result of the application of force. Besides these, we 
distinguish congenital, and spontaneous or pathological luxations. 
The latter result from gradual ulcerative destruction of the articular 
extremities and ligaments, since there is no longer the natural oppo- 
sition to muscular contraction ; we shall speak of this hereafter, as it 
essentially belongs among the results of certain diseases of the joints. 
At the end of this section we shall say something about congenital 
luxations. At present we shall speak only of traumatic dislocations. 
We occasionally hear also of subluxations/ by this expression we 
imply that the articular surfaces have not separated entirely, so that 
the luxation is incomplete. By complicated luxations we mean those 
accompanied by fractures of bones, wounds of the skin, or ruptures of 
large vessels, or nerves, or all of these. You must also observe that 
it is customary to designate the lower part of the limb as the part 
luxated ; as for instance at the shoulder-joint, not to speak of a lux- 
ated scapula, but of dislocation of the humerus ; at the knee-joint, not 
of luxation of the femur, but of the tibia, etc. 

Dislocations generally are rare injuries ; in some joints they are so 
rare that the whole number of cases known is scarcely half a dozen. 
It is said that fractures are eight times as frequent as dislocations ; it 
seems to me that even this is too large a proportion for dislocations. 
The distribution of luxations among the different joints varies very 
greatly ; let me show you this by some figures : According to Mai- 
gaigne's statistics, among 489 dislocations there were 8 of the trunk, 
62 of the lower and 419 of the upper extremity, and among the lat- 
ter there were 321 of the shoulder. Hence you see that the shoulder 
is a very favorite joint for dislocations, which is readily explained by 
its construction and free mobility. Dislocations are more frequent 
among men than women, for the same reasons that we have already 
shown fractures to be more frequent in men. 



DISLOCATIONS. 243 

As inducing causes for dislocations, we have external applications 
of force and muscular action ; the latter are rare, but cases have been 
observed where dislocations were caused, in epileptics, for instance, by 
muscular contractions. As in fractures, the external causes are divided 
into direct and indirect. For instance, if one gets a luxation by 
falling on the shoulder, it is due to direct force; the same luxation 
might occur indirectly by a person with outstretched arm falling on 
the hand and elbow. Whether a dislocation or a fracture will result, 
depends chiefly on the position of the joint and the nature of the 
cause ; but much also depends on whether the bones or the articular 
ligaments give way the more readily ; for instance, by the same manoeu- 
vre on different dead bodies we may sometimes cause fracture, some- 
times dislocation. As in fractures, there are numerous symptoms of 
luxation, of which some may be very noticeable, and are the more so 
the sooner we see the case, and the less the displacement of the ar- 
ticular ends is hidden by inflammatory swelling of the superjacent 
soft parts. The altered form of the joint is one of the most important 
and striking symptoms, but which only leads quickly and certainly to 
a diagnosis when the eye has been accustomed to readily recognize 
differences from the normal form. Correct measurement with the eye, 
accurate knowledge of the normal form, in short, some taste for sculp- 
ture and sculptural anatomy, so-called artistic anatomy, are here very 
useful. If there is very slight change of form, even the most prac- 
tised will not be able to dispense with a comparison with the opposite 
side, and hence I earnestly urge you, if you would avoid error, always 
to expose the upper or lower half of the body, as the case may be, 
and to compare the two sides. You may best follow with the eye 
the direction of the apparently displaced bone, and if this line does 
not strike the articular cavity accurately, there will most probably be 
a dislocation, if there be not a fracture, close below the articulating 
head of the bone, which must be determined by manual examination. 
The lengthening or shortening of a limb, its position to the trunk, 
the distance of certain prominent points of the skeleton from each 
other, often aid us in making at least a probable diagnosis very 
quickly. Another symptom perceptible to the sight is ecchymosis of 
the soft parts, or suggillation. This is rarely distinct at first, because 
the blood, escaping from the torn capsule only gradually, perhaps not 
for several days, rises near the skin and becomes visible ; in some 
cases the effusion of blood is so inconsiderable that it is not perceived. 
The symptoms given by the patient are, pain and inability to move the 
limb normally. The pain is never so great as in fractures, and only 
appears on attempting to move the limb. In some cases, patients 
with luxations may perform some motions with the limb, but only in 



244 INJURIES OF THE JOINTS. 

certain directions, and to a very limited extent. Manual examination 
must finally settle the question in most cases ; it must show that the 
articular cavity is empty, and that the head of the bone is at some 
other point, at one side, above or below. If the soft parts be consid- 
erably swollen, this examination may be quite difficult, and the aid 
of anaesthesia is often necessary for a correct diagnosis, especially if 
the exhibitions of pain and the motions of the patient interfere. On 
moving the extremity, which we find springy or slightly movable, 
there is occasionally a feeling of friction, an indistinct, soft crepitation. 
This may result partly from rubbing of the head of the bone on torn 
capsular ligaments and tendons, partly from the compression of firm 
blood-coagula. Hence, in such varieties of crepitation, we should not 
at once conclude on a fracture, but be urged to more careful examina- 
tion. Fractures of certain parts of the articular ends, with disloca- 
tion, are most readily mistaken for luxations. And formerly the mode 
of expression on this point was not exact, for displacements about 
the joint, combined with fractures, and caused entirely by them, were 
also termed luxations. At present we distinguish these fractures 
within the joint, with dislocations, more sharply from luxations 
proper. 

Should you be in doubt as to whether the case is one of dislocated 
articular fracture or of luxation, you may easily decide the question 
by an attempt at reduction. If such a dislocation is readily reduced 
by moderate traction, but at once returns when you leave off the 
traction, it is a case of fracture ; for a certain art is necessary to the 
reduction of a dislocation, and, when once reduced, it does not readily 
recur, although there are exceptions to this rule. 

A contusion and sprain of the joint may also be mistaken for lux- 
ation, but this error may be avoided by careful examination. Old 
traumatic luxations may sometimes be mistaken for dislocations caused 
by contraction. Lastly, in paralyzed limbs, where there is at the 
same time relaxation of the articular capsule, the joint may be so very 
movable that in certain positions it will look as if dislocated. In 
these cases, also, the history of the case and careful local examination 
will lead us to a correct conclusion. 

Regarding the state of the injured parts immediately after the in- 
jury, in cases where there has been a chance to examine them, it has 
been found that the capsule of the joint and the synovial membrane 
are torn. The capsular opening is of variable size ; occasionally it is 
a slit like a button-hole, sometimes it is triangular, with more or less 
ragged edges ; ruptures of muscles and tendons immediately around 
the joint have also been observed. The contusion of the parts varies 
greatly, as does also the effusion of blood. The head of the bone does 



REDUCTION OF DISLOCATIONS. 245 

not always remain at the point where it escapes from the ruptured 
capsule, but in many cases it is higher, lower, or to one side, as the 
muscles attached to it contract and displace it. It is important to 
know that we must frequently bring the luxated head of the bone into 
a different position before we can carry it back through the opening 
in the capsule into the articular cavity. 

Occasionally, by some accidental muscular action, the dislocation 
is spontaneously reduced. In the shoulder, especially, this has been 
observed several times. But such spontaneous reductions are very 
rare, because there are usually certain mechanical obstructions to the 
reduction, which must be overcome by skilful manipulation. These 
hinderances consist partly in contraction of the muscles, by which the 
head of the bone may be caught between two contracted muscles ; 
another far more frequent obstacle is a small capsular opening, or its 
occlusion by the entrance of the soft parts. Lastly, certain tensions 
of the capsular or strengthening ligaments may hinder the reposition 
of recent traumatic luxations. 

In treating a luxation it must first be skilfully reduced, and then 
means be employed for restoring the function of the injured limb. 
We shall here only speak of the reduction of recent dislocations, by 
which we mean those that are at most eight days old. The most 
favorable time for reducing a dislocation is immediately after the in- 
jury ; then we have the least swelling of the soft parts, and little or 
no displacement of the luxated head of the bone ; the patient is still 
mentally and physically relaxed from the accident, so that the reposi- 
tion is not unfrequently very easy ; later, we shall often have to facili- 
tate the operation by resorting to anaesthetics to remove the opposition 
of the muscles. Regarding the proper manoeuvres for the reduction, 
we can say but little in general terms, for this of course depends en- 
tirely on the mechanism of the different joints. Formerly, it was a 
general rule, for the reduction of dislocations, that the limb should be 
brought into the position in which it was at the moment of the dislo- 
cation, so that by traction the head of the bone might be replaced as 
it had escaped. This rule is only important in a few cases ; at present, 
in the different dislocations we are more apt to resort to very different 
motions, such as flexion, hyper-extension, abduction, adduction, eleva- 
tion, etc. Usually, the surgeon directs the assistants to make these 
motions, and himself pushes the head of the bone into place when it 
has been brought before the articular cavity. 

Frequently the surgeon alone can accomplish the reduction. I 
have often thus reduced a dislocation of the thigh over which various 
colleagues, aided by muscular laborers, had worked in vain for hours. 
In these cases, every thing depends on correct anatomical knowledge, 



246 INJURIES OF THE JOINTS. 

and you may readily understand that in a certain direction you may 
not unfrequently slip the head of the bone into place with very little 
force, while in another position it might be entirely impossible. When 
the head of the bone enters the articular cavity, it occasionally causes 
a perceptible snap ; but this does not always occur ; we are only per- 
fectly assured of successful reposition by the restoration of normal 
mobility. 

If we do not succeed alone, or with a few assistants, we have 
various aids, by applying long slings to the limb, and having several 
assistants draw in one direction. This traction, which of course must 
be opposed by a counter-extension of the body, must be regular, not 
by starts. If we do not succeed, even in this way, we call in the aid 
of machinery to increase the power. For this purpose various instru- 
ments were formerly employed, such as the lever, screw, ladders, etc. 
Now the multiplying pulleys, or Sehneider-MeneVs extension-appara- 
tus, is almost exclusively used. The multiplying pulleys, an instru- 
ment that you already know from your studies in physics, for increas- 
ing power, and which is greatly resorted to in mechanics, are used as 
follows : One end of the rope is fastened to a strong hook in the wall, 
while the other is applied to the limb by straps and buckles. Counter- 
extension is made on the body of the patient, so that it shall not 
be moved by the extension. An assistant draws on the pulleys, 
whose power of course increases with the number of rollers employed. 
Schneider-MeneVs apparatus consists of a strong gallows, to the inner 
side of one post of which is attached a movable windlass, which may 
be turned by a handle and held by a toothed wheel ; over this wind- 
lass runs a strap which is attached by a hook to a bandage applied 
around the luxated extremity. In luxation of the lower extremity the 
patient lies on a table placed lengthwise between the posts of the gal- 
lows, or for reduction of an arm he may be seated on a chair placed 
the same way ; the counter-extension is made by straps by which the 
patient is fastened to the other post of the gallows. Both of these 
apparatuses have certain advantages, but both are troublesome to ap- 
ply. In your practice you will have little to do with them, as they 
are almost exclusively employed in old dislocations whose treatment 
is more rarely undertaken in private practice than in hospitals and 
surgical clinics. 

At present, when we undertake this forcible reduction, it is always 
under the influence of anaesthetics. To produce complete relaxation 
this anaesthesia must be very profound, and, as the chest is often cov- 
ered with straps and girdles for counter-extension, the anaesthetic 
must be very carefully employed to avoid dangerous results. But 
there are also other dangers which were known to the older surgeons, 



REDUCTION OF DISLOCATIONS. 247 

who did not u,e chloroform. These are as follows : If the patient is 
tried too long with these powerful remedies, he may suddenly collapse 
and die ; moreover, the limb may become gangrenous from the press- 
ure of the straps, or there may be subcutaneous rupture of large nerves 
and vessels, and consequent paralysis, traumatic aneurism, extensive 
suppuration, and other dangerous local accidents. The results of 
pressure from the appliances may best be avoided by applying a moist 
roller-bandage from below upward, and fastening the straps over this. 
Since a regular pressure is thus made over the entire limb, the press- 
ure of the appliance close above the joint does not prove so injurious. 
The time during which we may continue these forcible attempts at 
replacement should be at most half an hour ; if we do not succeed in 
this time, we may be pretty certain of not doing so at all. If we 
wish to try further in such cases, we should resort to some other 
method. Until recently, we had no measure of the force that could 
be used without danger, and had to content ourselves with estimating 
it. It seems scarcely possible, by the above means, to tear out an 
arm or a leg ; but not long since this did occur in Paris, and in a case 
where only manual extension was employed ! Generally, the straps 
tear sooner, or the buckles bend. Subcutaneous ruptures of the nerves 
and vessels would scarcely be caused in a healthy arm by regular trac- 
tion on the whole extremity ; but they may tear, when adherent to 
deep cicatrices, and are so atrophied as to have lost their normal elas- 
ticity. If, under such circumstances, the conditions could always be 
accurately appreciated beforehand, we should frequently entirely ab- 
stain from attempts at reduction ; for, in such cases, rupture of a nerve 
or vessel may follow attempts at reposition with the hand, and we 
cannot refer the accident to the machinery. An instrument has been 
invented, by whose aid the force employed in extension may be meas- 
ured. This instrument should be inserted in the extension-apparatus, 
and shows the force employed in weight, as is customary in physics. 
According to Malgaigne, we should not go above two hundred kilo- 
grammes with this dynamometer ; but such directions are of course 
only approximative. 

If the reduction has been accomplished, the main point has cer- 
tainly been gained, but some time is still required for full return of 
the function of the limb. The wound in the capsule must heal, for 
which purpose perfect rest of the joint for a longer or shorter time is 
requisite. After reposition there is always moderate inflammation of 
the synovial membrane, with a slight effusion of fluid into the joint, 
and the latter remains for a time painful, stiff, and unwieldy. If re- 
duction has closely followed the injury, the joint must first be kept per- 



248 INJURIES OF THE JOINTS. 

fectly quiet ; it is surrounded with moist bandages, and cold compresses 
are applied ; the swelling is rarely so great as to demand other anti- 
phlogistic remedies. In the shoulder-joint after ten to fourteen days we 
begin passive motion and continue it till active movements can be 
made and the arm is fully useful ; frequently, it is many months before 
movements are quite free, and elevating the arm is the last motion to 
return. In other joints that have less mobility, active movements 
may be permitted much sooner ; thus they are restored especially early 
in the elbow and hip-joints, and in the latter joints we may permit 
attempts at motion the earlier, because there luxations do not so 
readily recur. 

If active motions be permitted too soon after reduction of a dis- 
location, especially in those joints where dislocation readily recurs, as 
in the shoulder and lower jaw, and if the luxation recurs once or sev- 
eral times before the capsular opening has healed, occasionally the 
capsule does not heal completely, or there is so much distensibility of 
the capsular cicatrix that the patient only has to make a careless 
motion to luxate the part again. Then we have the state called 
habitual luxation, a very annoying state, especially in the lower jaw. 
I knew a woman who had a dislocation of the jaw and did not take 
care of herself long enough afterward, so that it soon returned and 
had to be reduced again ; the capsule was so much stretched that, if, 
in eating, she took too large a morsel of food between the back teeth, 
she at once luxated the jaw ; she accustomed herself to the manoeuvre 
of slipping it into place, so that she could do it with the greatest 
facility. Such an habitual luxation of the shoulder may occur in the 
same way. I have seen a young man, who, when gesticulating vio- 
lently, had carefully to avoid raising his arm quickly, as he almost 
alwaj's dislocated it by this motion ; such a state is very annoying, 
and is difficult to cure ; recovery would only be possible by long 
rest of the joint, but patients rarely have inclination or patience for 
this treatment. It is well for such patients to wear a bandage that 
will prevent lifting or throwing back the arm too much ; if the luxa- 
tion be avoided for a few years, it will not recur so readily. 

If a simple dislocation be not recognized and reduced, or if, for 
various reasons, we cannot reduce it, a certain amount of mobility is 
nevertheless restored, which may be considerably increased by regu- 
lar use. From the relation of the head of the bone to adjacent bony 
processes, and from displacement of muscles, it may be readily under- 
stood that, for purely mechanical reasons, certain motions will be im- 
possible, while others may approximate the normal mobility. But, 
if the movements be not methodically restored, the limb remains stiff, 
the muscles become atrophied, and the limb is of little use. The 



CHANGES IN OLD LUXATIONS. 249 

anatomical changes in the joint and parts around are as follows : the 
extra vasated blood is reabsorbed; the capsule folds together and 
atrophies ; the head of the bone rests against some bone in the vicin- 
ity of the articulating cavity ; for instance, in luxation of the humerus 
inward against the ribs under the pectoralis major, the soft parts 
about the dislocated head become infiltrated with plastic lymph and 
transform to cicatricial connective tissue, which partly ossifies, so 
that a sort of bony articular cavity again forms, while the head is 
surrounded by a newly-formed connective-tissue capsule. In the 
cartilage of the head of the bone, the following changes visible to the 
naked eye occur : the cartilage becomes rough, fibrous, and grows 
adherent to the parts on which it lies, by a cicatricial, firm connective 
tissue. In the course of time this adhesion becomes very firm, espe- 
cially if not disturbed by movements. The metamorphosis of cartilage 
to connective tissue, followed microscopically, takes place as follows : 
the cartilage-tissue divides directly into fine filaments, so that the 
tissue acquires first the appearance of fibrous cartilage, then of ordi- 
nary cicatricial connective tissue, which unites with the parts around 
and receives vessels from them. The surrounding muscles, as far as 
they are not torn, lose a large part of their filaments, partly from 
molecular disintegration, partly from fatty metamorphosis of the con- 
tractile substance; subsequently, new muscular filaments form in 
these muscular cicatrices. 

This is what we call an old luxation, and it is in such cases espe- 
cially that the above methods of forcible reduction are employed. 
The question, how long a luxation must have existed before its repo- 
sition is to be considered impossible, cannot be answered since the 
introduction of chloroform, and is to be differently answered for the 
various joints. Thus, dislocations of the shoulder may be reduced after 
existing for years, while those of the hip-joint two or three months 
old are reduced with difficulty. The chief obstacle lies in the firm 
adhesions of the head of the bone in its new position, and in the loss 
of contractility of the muscles, and their degeneration to connective 
tissue. Another question is, whether, when such old dislocations are 
reduced, we attain the desired effect on the function, especially in the 
shoulder. Imagine that the small articulating cavity is filled by the 
atrophied capsule, and that the head of the bone has lost its cartilage, 
then, even if we succeed in bringing the head to its normal position, 
restoration of function may still be impossible, and I can assure you, 
from my own experience, that the final result of a very tiresome and 
long after-treatment in such cases does not always repay the patience 
and perseverance of the patient and surgeon. In such cases, the result 
will scarcely be more favorable than if the patient tries, by methodical 



250 INJURIES OF THE JOINTS. 

exercise, to make his limb as useful as possible in its new position, 
which it may have occupied for months or years. We may facilitate 
this exercise by breaking up the adhesions about the head of the bone, 
by rotating it forcibly while the patient is anaesthetized. If, as occa- 
sionally happens in shoulder-dislocations, the head of the bone in its 
abnormal position so presses on the brachial plexus as to cause paraly- 
sis of the arm, if reduction be impossible, it may be advisable to make 
an incision down to the head of the bone to dissect it out and saw it 
off, i. e., to make a regular resection of the head of the humerus. I 
have seen a case where, in complete paralysis of the arm after a luxa- 
tion of the humerus downward and inward, decided improvement of 
the function of the arm was attained by the above operation, although 
there was not complete recovery of the paralysis. 



COMPLICATED DISLOCATIONS. 

A dislocation may be complicated in various ways; most fre- 
quently with partial or entire fracture of the head of the bone, which 
is difficult to cure, and in which reposition is often only partly suc- 
cessful ; in treatment, attention must always be paid to the fracture ; 
i. e., a dressing must be worn till the fracture has united. At the 
same time it is advisable to renew the dressing frequently, say every 
week, and to apply it in a different position each time, so that the 
joint may not become stiff. Nevertheless, we cannot always succeed 
in attaining perfect mobility, so that I can only advise you in your 
practice always to give a doubtful prognosis in such cases. 

Another complication is a coincident wound of the joint. For 
instance, the broad articular surface of the lower epiphysis of the 
humerus or of the radius may be driven out of the joint with such 
force as to tear through the soft parts and skin, and lie exposed. 

Of course the diagnosis is easy in such cases ; reposition is accom- 
plished according to the above rules, but we still have a wound of the 
joint ; and we are liable to all the chances spoken of under wounds 
of joints, so that for the prognosis, the varieties of the possible results 
and the treatment, I refer you to what has already been said (p. 224). 
Of course, it is worse when there is an open fracture through the joint ; 
here we can neither expect rapid closure of the wound nor restoration 
of the function of the joint, and we run all the dangers that threaten 
complicated open fractures and wounds of joints. The decision as to 
what must be done in such cases is easy, when there is at the same 
time considerable crushing or tearing of the soft parts ; under such 
circumstances, primary amputation must be done. If the injury of 



CONGENITAL LUXATIONS. 251 

the soft parts be not great, we may sometimes hope for a cure by 
suppuration, with a subsequent stiff joint ; but, as experience shows, 
this is always a dangerous experiment. According to the principles 
of modern surgery, in such cases we avoid amputation by dissecting 
out and sawing off the fractured articular ends of the bones so as to 
make a simple wound. This is the regular total resection of a joint, 
an operation concerning which very extensive observations have been 
made during the last twenty years, and of which modern times is 
justly proud ; by its means many limbs have been preserved, which, 
according to the old rules of surgery, should unhesitatingly have been 
amputated. 

In regard to their danger, these resections vary greatly according 
to the joint on which they are made, so that it is difficult to make any 
general remarks about them. But, in a subsequent section (in the 
treatment of chronic fungous diseases of the joints), we shall study 
this very important point more carefully ; what has been said will give 
you a general idea of a resection of the joint. 



CONGENITAL LUXATIONS. 

Congenital luxations are rare, and we must distinguish them from 
luxationes inter partum acquisitce, i. e., those that have resulted at 
birth from manoeuvres in extracting the child, and which are merely 
simple traumatic luxations which may be reduced and cured. Al- 
though congenital luxations have been observed in most of the joints 
of the extremities, they are particularly frequent in the thigh, and not 
unfrequently occur on both sides at the same time. The head of the 
bone stands somewhat above and behind the acetabulum, but in many 
cases it can readily be replaced. As a rule, the disease is first noticed 
when the child begins to walk. The most noticeable symptom is a 
peculiar wabbling gait, which is caused by the head of the bone 
standing behind the acetabulum so that the pelvis inclines forward, 
and also because in walking the head of the thigh moves up and down ; 
there is never any pain. To examine the child more accurately, you 
may unclothe it entirely and watch its gait ; then lay it on the back, 
and compare the length and position of the extremities. If the luxa- 
tion be one-sided, the luxated limb will be shorter than the other, and 
•the foot turned inward ; if you fix the pelvis, you may often reduce 
the dislocation by simple traction downward. The anatomical exami- 
nation of such joints has led to the following results : not only is the 
head of the bone out of the socket, but the socket is irregularly 
formed — too shallow ; later in life, in adults, it is greatly compressed 



252 INJURIES OF THE JOINTS. 

and filled with fat ; when the ligamentum teres exists, it is abnoimally 
long ; the head of the bone is not properly developed ; in some cases 
it is not half as large as normal ; the articular cartilage is usually 
completely formed, the capsule very large and relaxed. 

Under such circumstances, you may understand that it is exceed- 
ingly difficult, in most cases impossible, to effect a cure. If the head 
be only partially developed, the upper border of the acetabulum ab- 
sent, and the capsule enormously distended, how shall we restore the 
normal conditions ? As to the causes of this malformation, the most 
varied hypotheses have been advanced ; the opportunity has never 
occurred of studying it in the embryo. There is an arrest of develop- 
ment from some cause. It is assumed that these disturbances followed 
previous pathological processes in the foetus, and the most probable 
hypothesis is that, in very early embryonal life, the joint was filled 
with an abnormal quantity of fluid, and so distended as to induce rup- 
ture or at least great dilatation of the capsule. Hoser thinks that 
abnormal intra-uterine positions may give rise to these luxations. 

Cure of this state has been attempted in those cases where direct 
examination has shown the existence of a tolerably-developed head. 
In such cases the luxation has been reduced, and attempts made to 
preserve the normal position of the thigh by aid of dressings or band- 
ages — the child being kept quiet for a year or more. The result of 
this treatment, which requires great patience on the part of the sur- 
geon and parents of the child, is shown by experience to be only 
partially satisfactory, as after this treatment there has only been an 
improvement of the gait, but rarely a perfect cure ; and, when you read 
in orthopedic pamphlets of the frequent cure of congenital luxations, 
you may be sure that in most cases there have been errors of diag- 
nosis, or there is intentional deception. 

Congenital luxations of the thigh are never dangerous to life, but, 
since they are accompanied by a change in the centre of gravity of 
the body, in the course of time they have an effect on the position 
and curvature of the vertebral column ; this, and a limping, wabbling 
gait, are the only inconveniences they cause. There can only be a 
hope of successful treatment in very early youth ; but, as the surgeon 
cannot promise a successful result in less than one to three years, few 
patients are put under treatment. 

I will here mention a very rare occurrence, which I have only 
met with once. In certain movements the tendon of the long head 
of the biceps brachii may slip out of its groove and hang on the bor- 
der of the greater or lesser tubercle ; then the arm stands fixed in a 
slightly abducted position. If we hold the shoulder-blade steady 
and relax the tendon by slowly raising the arm, then by slightly 



CONGENITAL LUXATIONS. 253 

rotating the arm we can easily slip the tendon into place ; the pain 
ceases at once, and all motions are free. For this luxation to occur, 
the fascia-like membrane which covers the sulcus must tear or be 
much relaxed. The former is improbable ; where the latter is the 
case, the accident readily recurs. Some persons have the covering 
of the sulcus, in which the tibialis posticus muscle lies, so relaxed 
that they can voluntarily luxate this tendon and let it snap into 
place with an audible sound. 

[Cases where the tendon of the quadriceps femoris and patella 
may be voluntarily luxated and snapped back into place are prob- 
ably less rare. The translator, among other cases, has had one pa- 
tient 18 months old who could do this at pleasure, and when irritated 
about any thing would snap his patella even if his leg were firmly 
held. This leg having been placed in a plaster dressing, he began 
the same performance with the other leg. Then both legs were left 
free, and after some weeks, when his general health and temper im- 
proved, the phenomenon ceased.] 



CHAPTER VIII. 
G UJSTSHO T-WO ZrJSTJDS, 



LECTURE XIX. 

Historical Kemarks. — Injuries from Large Missiles. — Various Forms of Bullet-Wounds. 
— Transportation and Care of the Wounded in the Field. — Treatment.— Complica- 
ted Gunshot-Fractures. 

In war many injuries occur that are to be classed among simple 
incised, cut, punctured, and contused wounds ; gunshot-wounds them- 
selves must be classed with contused wounds ; but they have some 
peculiarities that entitle them to separate consideration, in doing 
which we must briefly come in contact with the domain of military 
surgery. Since fire-arms were first used in warfare (1338), gunshot- 
wounds have received special attention from surgical writers, so that 
the literature on this subject has become very extensive ; of late, in- 
deed, military surgery has been made almost a separate branch, which 
includes the care of soldiers in peace and war, and the special hygienic 
and dietetic rules which are so important in barracks, in stationary 
and field hospitals, also the clothing and food. Although the Romans, 
as was mentioned in the introduction, had surgeons appointed by the 
state with the army, in the middle ages it was more common for every 
leader of a troop to have a private doctor, who, with one or more 
assistants, very imperfectly took care of the soldiers after a battle, 
and then usually went on with the army, leaving the wounded to the 
care of compassionate people, without the commander or the army 
taking the responsibility. 

It was not till standing armies were formed that surgeons were 
detailed to certain battalions and companies, and certain (still very 
imperfect) rules and regulations were made for the care of the 
wounded. The position of military surgeon was, in those days, very 
ignoble, and such as we do not hear of now ; for, even in the time of the 
father of Frederick the Great, the army surgeon was publicly flogged 
if he permitted one of the long grenadiers to die. At that time, wheD 



VARIOUS FORMS OF BULLET-WOUNDS. 255 

the troops marched to meet the enemy at a parade-step, the move- 
ments of the army were very tedious and slow ; the large armies had 
immense trains ; for instance, in the Thirty Years' War, the lancers car- 
ried along their wives and children in innumerable wagons ; hence, in 
the medical arrangements pertaining to the train, there was no ne- 
cessity for greater facilities of motion. The tactics started by Fred- 
erick the Great required greater mobility of the heavy trains, which, 
however, was only practically carried out in the French army under 
Napoleon. As long as a small province remained the seat of war 
during a whole campaign, a few large hospitals in neighboring cities 
might suffice ; but, when armies moved about rapidly and had a fight 
now here now there, it became necessary to furnish more movable, 
so-called field hospitals, not far from the field of battle, and which 
could be readily moved from place to place. These ambulances, or 
flying hospitals, are the idea of one of the greatest of surgeons, Lar- 
rey, of whom we have already spoken. As I shall shortly tell you 
what is done with the wounded from the time they are injured till 
they enter the general hospital, I will here dismiss this subject, and 
only mention some of the many excellent works on military surgery. 
Especially interesting, not only medically but historically, are the 
somewhat lengthy " Memoirs of Larrey," in which I especially recom- 
mend to you the Egyptian and Russian campaigns. These memoirs 
contain all Napoleon's campaigns. Another excellent work we have 
in English literature, John Hennerts "Principles of Military Sur- 
gery ; " and in German, besides many other excellent works, we have 
'" The Maxims of Military Surgery," by Stromeyer, which is composed 
chiefly of experiences in the Schleswig-Holstein War ; and, lastly, 
" Principles of General Military Surgery, from Reminiscences in the 
Crimea and Caucasus, and in the Hospital," by Dr. JPirogoff. 

Wounds caused by large missiles, such as cannon-balls, grenades, 
bombs, shrapnel, etc., are partly of such a nature that they kill at once, 
in other cases tear off whole extremities, or so shatter them that am- 
putation is the only remedy. The extensive tearing and crushing 
caused by these shot do not differ from other large crushed wounds 
caused by machinery, which unfortunately now so often occur in 
civil practice. 

Musket-balls used in modern warfare differ in some respects : 
while the small copper bullets with which the Circassians shoot are 
scarcely larger than our so-called buckshot, large, hollow, leaden bul- 
lets were used in the late Italian War ; these were much larger than 
the old-fashioned ones, and were particularly dangerous, because they 
readily broke upon striking a bone or tense tendon. Besides these, 
the solid round and conical bullet are used, but their effects do not 



256 



GUNSHOT-WOUNDS. 



Fig. 58. 






«, Chassepot ; b, needle-gun ; c, mitrailleuse-projectiles. Natural size. 



differ much. The Prussian long bullet, which is held in the cartridge 
of the needle-gun, is a solid bullet of the form and size of an acorn. 
You must not think that the projectile, as found in the wound, has the 
same shape as when put in the gun ; but it is changed in form as it 
comes out of the rifles of the gun, and is also flattened in the wound, 
so that we often find it a shapeless mass of lead, which scarcely shows 
the form of the projectile. We shall now briefly consider the varioU3 
injuries that may be caused by a bullet ; in doing which, we shall 
naturally confine ourselves to the chief forms. 

In one set of cases the bullet makes no wound, but simply a con- 
tusion of the soft parts, accompanied by great suggillation and occa- 
sionally by subcutaneous fracture. According to recent authorities, 
simple subcutaneous fractures are not very uncommon in war. These 
injuries are caused by spent bullets, i. e., such as come from a long dis- 
tance and have not force enough to penetrate the skin ; such a bullet, 
striking over the liver, may push the skin before it and make a depres- 
sion in or a rupture of the liver, and then fall back without producing an 
external wound. Like injuries are caused by bullets striking the skin 
at a very oblique angle. Firm bodies, such as watches, pocket-books, 
coins, leather straps on the uniform, etc., may also arrest the bullet. 
These contused wounds, which, especially when affecting the abdomen 
or thorax, may prove very dangerous, have always excited the atten- 
tion of surgeons and soldiers ; formerly they were always referred to 
the so-called " wind of the ball," and it was thought that they were 
caused by the bullet passing very close to the body. The idea thai 
injuries could be caused in this way was so firmly established, that 
even very well-informed persons worried themselves in trying to ex- 
plain theoretically how the}' resulted from the wind of the ball. One 
said that the air in front of and near the bullet was so compressed 



VARIOUS FORMS OF BULLET-WOUNDS. 257 

that the injury was due to this pressure ; another thought that, from 
the friction in the barrel of the gun, the bullet was charged with 
electricity, and could in some unknown manner cause contusion and 
burning at a certain distance. If the conclusion that the whole idea 
of the wind of balls was a fable had been arrived at sooner, these 
fantastic theories would not have arisen. Contusions from spent and 
oblique bullets are to be treated like other contusions. 

In the second case, the bullet does not enter the soft parts deeply, 
but carries away part of the skin from the surface of the body, leaving 
a gutter or furrow. This variety of gunshot- wound is one of the 
slightest, unless, as may happen in the head, the bone is grazed by 
the bullet, and portions of lead remain in the skull. 

The third case is where the bullet enters the skin without escap- 
ing again ; the bullet enters and generally remains in the soft parts ; 
it makes a tubular wound. Various other foreign bodies may be car- 
ried into these wounds, such as portions of uniform, cloth, leather, 
buttons, etc. ; a bone may also be splintered, and the splinters driven 
into the wound and tear it. After perforating the skin and soft 
parts, the bullet might rebound from a bone and fall out of the same 
opening, so that you would not find it in the wound, in spite of there 
being only one opening. The wound that the bullet makes on entering 
the body is usually round, corresponding to the shape of the ball ; its 
edges are contused, occasionally bluish-black, and somewhat inverted. 
These characteristics hold in the majority of cases, but are not ab- 
solute. 

The fourth and last case is where the bullet enters at one point and 
escapes at another. If the course of the wound is entirely through 
the soft parts, and the bullet has carried in no foreign body, the point 
of exit is usually smaller than the entrance, and is more like a tear. 
If the bullet has struck a bone and driven bone-splinters or other for- 
eign body before it, the point of exit is occasionally much larger than 
the entrance ; there may also be two or more points of exit from 
bursting of the bullet into several pieces or from several splinters of 
bone. Lastly, splinters of bone may make openings of exit like those 
from a bullet, while the latter, or part of it, remains in the wound. 
Too much value has been attached to the distinction of the openings 
of entrance and exit ; this is only important in forensic cases, where 
it may be desirable to know from which side the bullet came, as this 
may give a clew to the author of the injury. The course of the bullet 
through the deep parts is occasionally very peculiar ; its course is some- 
times deviated by bones or tense tendons and fasciae, so that we 
should be greatly mistaken in supposing that the union of the points 
of entrance and exit by a straight line always represented the course 
17 



258 GUNSHOT-WOUNDS. 

of the bullet. In this respect, the encircling of the skull and thorax 
is most peculiar : for instance, a bullet strikes the sternum obliquely, 
but without sufficient force to perforate this bone ; the bullet may 
run along a rib under the skin to the side of the thorax, or even to 
the spinal column, before escaping again ; from the position of the 
points of entry and exit, we might suppose the bullet had passed 
directly through the chest, and be greatly astonished when such 
patients come, without any difficulty of breathing, to have their wound 
dressed. 

The complication of gunshot-wounds with burns by powder, such 
as results from shooting at close quarters, rarely occurs in war. It is 
not rare in cases of accidents from careless handling or bursting of 
fire-arms, or from blasting, and may cause the greatest variety of 
burn. The burnt particles of powder often enter the skin and heal 
there, giving it a bluish-black appearance for the rest of life. More 
of this in the chapter on burns. 

In gunshot injuries, there is said to be scarcely any pain ; the rapidity 
of the injury is such that the patient only feels a blow on the side 
from which the bullet comes, and does not for some time perceive the 
bleeding wound and actual pain. There are numerous examples 
where combatants have received a shot, especially in the upper ex- 
tremity, without knowing it till told by some one, or having their 
attention attracted by the flow of blood. 

In gunshot, as in contused wounds, the bleeding is usually less 
f han in incised and punctured wounds ; but it would be a great mis- 
take to suppose that arteries which have been shot through do not 
bleed. On the contrary, many soldiers never leave the battle-field, 
having died from rapid haemorrhage from large arteries. When one 
has seen a fully-divided carotid, subclavian, or femoral artery bleed, 
he will know that in a very short time the loss of blood will be so 
great that the only hope of safety lies in immediate aid ; so that a 
haemorrhage of two minutes' duration from one of these arteries is 
certainly fatal. But arteries, even as large as the radial, often bleed 
but little. The first surgeons who gave us descriptions of gunshot- 
wounds called attention to this point. 

Before passing to the treatment of gunshot-wounds, I would 
briefly picture to you the transportation of and first aid offered to the 
wounded in battle. For the first aid there are usually established 
certain temporary places for dressing the wounded, in some sheltered 
place close behind the line of battle, usually in rear of the batteries ; 
these are designated by white flags. The wounded are first brought 
to this spot, either by soldiers or by a trained ambulance corps. Of 
course, those wounded slightly or in the upper extremities walk to the 



CARE OF THE WOUNDED. 259 

spot. The ambulance corps has proved so efficient in late wars that 
it will certainly be more trusted to in future. It is composed of 
nurses trained to bring the wounded from the field, and, when neces- 
sary, to give them temporary aid, as in arresting bleeding from arte- 
ries and wounds, etc. They have been trained to carry a patient 
between two of them, either without other support, or on an impro- 
vised litter. For this latter purpose they usually carry a lance and a 
piece of cloth longer and broader than the body. The lances are 
passed through hems along the sides of the cloth, and a barrow is 
thus made ; bayonets or swords may be used as provisional splints for 
supporting a limb that has been badly shot. The wounded are thus 
brought to the dressing-place, and the first dressings are applied ; 
these remain on till the patient reaches the nearest field-hospital. At 
the same time haemorrhage must be securely arrested, and injured 
limbs so arranged that transportation may do no harm ; bullets, for- 
eign bodies, and loose splinters of bone near the surface, should be 
removed, if it can be done quickly and readily. Limbs that have 
been entirely crushed by large shot should be at onee amputated, if a 
dressing cannot be so applied as to render transportation possible. 
The chief object of this dressing-place is to render the wounded 
transportable ; hence it is not proper to do many or tedious operations 
there. From the great pressure of the constantly-increasing throng 
from the front, only the most important cases can be attended to here, 
and Pirogoff is right, though it seems cruel, when he says the sur- 
geons should not exhaust their strength on the mortally wounded and 
the dying. But, if possible, every patient, when carried to the 
field-hospital, should receive a short written account of what was 
found at the first examination ; a card, containing a few words, thrust 
into one of his pockets is enough. The chief point is to tell whethei 
the ball has been extracted, whether a wound of the breast or abdo- 
men is perforating, etc., which will save time to the surgeon at the 
hospital and pain to the patient. Part of the ambulance corps has 
the further duty of placing the wounded properly in wagons for fur- 
ther transportation, under direction of the surgeon. For this purpose 
there are special ambulauces, constructed most variously, which take 
some patients lying down, others sitting up. There are rarely enough 
of these, and it is often necessary to use common wagons, covered 
with hay, straw, etc. These wagons convey the wounded to the next 
field-hospital, which is established in a neighboring city or town ; 
for it the largest attainable rooms should be taken. School-houses, 
churches, or barns, may be seized, although the latter are the best. 
In these places beds are prepared with straw, a few mattresses, and 
bedclothes. Surgeons and nurses await anxiouslv the arrival of the 



260 GUNSHOT-WOUNDS. 

first load of patients, having been already notified of the commence- 
ment of the battle by the thunder of the artillery. Here begins the 
accurate examination of patients, who were only temporarily dressed 
on the field, and here operating goes on most actively. Amputations, 
resections, extractions of bullets, etc., are done by wholesale, and the 
surgeon who has been anxious for his first operation on a living 
patient may operate till he stops from exhaustion. This continues 
till far into the night ; the fight lasts till late in the evening, and it is 
near morning before the last loads of wounded come in. With bad 
fights, on a temporary operating-table, and often with unskilful nurses 
for assistants, the surgeon must at once examine every patient, down 
to the last, and then operate and dress his wounds. In the field-hos- 
pitals the wounded have a period of rest, and, if possible, those who 
have been operated on or are seriously hurt should not be moved to 
another hospital till healthy suppuration begins and healing has at 
least commenced. This cannot always be done. Occasionally the 
place where the field-hospital has been established must be vacated. 
If one belongs to the vanquished party, and the enemy takes the place 
where the field-hospital was established, the surgeons are usually taken 
prisoners with their wounded; for, even when the enemy is most 
humane, after a great battle there is often such a demand for surgeons 
that those of the enemy cannot take the proper care of wounded 
prisoners. A few years since, in Geneva, a convention of European 
powers determined that surgeons and sanitary supplies should be con 
sidered neutral. Although there are some practical difficulties in 
carrying out this principle, it has done great good in the wars of late 
years, and is capable of still further development. At all events, the 
idea of considering a wounded enemy as an enemy no longer, but as 
a patient, is to be prized as a beautiful evidence of advancing hu- 
manity. 

When the wounded have all been brought under cover, bedded, 
and the necessary operations done, and the diet, etc., has been at- 
tended to, arrangements should be made for their proper disposition. 
Permanent collection of many wounded men in one place is injurious, 
and, when the seat of war is a poor country, with few railroad con- 
nections, the care of the wounded is particularly difficult. Hence, 
they should be sent off as soon as possible. This may be done, even 
with the severely wounded, when there is a railroad handy ; when the 
transportation is less convenient, the more slightly wounded at least 
can be removed. This system of scattering, which of late has been 
conducted with excellent results, requires great circumspection and 
trouble from the superior medical and military authorities, but it has 
proved advantageous. If houses (barracks), or, in summer, tents, cau 



TREATMENT OF GUNSHOT-WOUNDS. 261 

be erected for those remaining — the severely wounded — that will be 
best. If this be not practicable, they may be distributed in private 
houses ; it has proved unadvisable to leave the wounded in school- 
houses and churches. 

The war in North America, as well as that between Austria and 
Prussia in 1866, showed that there were still improvements to be 
made in military sanitary arrangements. A factor has been added 
that never before came as an aid, namely, extensive assistance from 
societies, Sisters of Charity, civil surgeons, and many other persons 
who, either personally or by money and stores, aided in the care of 
the wounded. "When this private aid is properly organized, under 
proper management of the military officers, it may be very useful. 

Concerning the treatment of gunshot-wounds, views have greatly 
changed from time to time, according to the point of view from which 
they were regarded. The oldest surgeons whose opinions we have, 
considered them as poisoned, and thought, consequently, that they 
should be treated with the hot iron or boiling oil. The first to op- 
pose this view successfully was Ambrose Pare, whom you already 
know to have introduced the ligature for arteries. He relates that in 
the campaign in Piedmont (1536) he ran short of oil for burning the 
wounds, and he expected the death of all the patients who could not 
be treated according to the rules of the time. But this did not hap- 
pen ; on the contrary, they did better than the chosen few on whom 
he used the remains of his oil. Thus a lucky accident tolerably soon 
freed medicine of this superstition. Later it was very correctly ob- 
served that the great difficulty in healing gunshot-wounds was due to 
the narrowness of the canal, and attempts were made to obviate this 
by plugging the wound with charpie or gentian-root. But sensible 
surgeons soon saw that this still more impeded the escape of pus 
from the deeper parts, and the correct view commenced to make 
some headway, that a gunshot-wound was a tubular contused wound. 
They sought to improve this in a peculiar way, by laying down the 
rule that every superficial gunshot-wound should be laid open, the 
opening of a canal leading into the deeper parts was to be enlarged 
by one or more incisions ; various methods were proposed for chan- 
ging the contused wound into a simple incised wound by these in- 
cisions, while, in fact, the only thing that was done was to add an 
incised wound to the gunshot-wound. The case was somewhat dif- 
ferent when the rule was given to cut out the whole course of the 
canal, and close the resulting canal by sutures and compresses, so as 
to obtain healing by first intention ; this proceeding cannot often be 
applied, and obtained little reputation. Of late, since the treatment 
of all wounds is so much simplified, the same thing has happened to 



262 



GUNSHOT-WOUNDS. 



Fig. 59. 



gunshot-wounds which are treated on the same general principles as 
contused wounds. In these, as in other wounds, the first thing is to 
arrest any arterial haemorrhage. This is to be done according to the 
rules already given, the bleeding artery 
being tied either in the wound itself, or 
the corresponding arterial trunk being 
ligated in its continuity ; to accomplish 
the former, it is generally necessary to 
enlarge the opening of entrance or exit, 
otherwise we should not find the bleed- 
ing artery. If there be no haemorrhage, 
we should examine the wound, especially 
any blind canal, for foreign bodies, par- 
ticularly for the bullet. This may be 
done most certainly with the finger ; 
should it not be long enough, or should 
the canal be too narrow, we may best 
use a silver female catheter, with which 
we may feel more certainly and safely 
than with a probe ; if we feel the bullet, 
we try to remove it the shortest way, 
that is, either draw it out at the point 
of entrance, or, if it lies in a blind canal, 
close under the skin, we make an inci- 
sion through the skin and extract it 
through this, thereby changing the blind 
canal into a complete one. The extrac- 
tion of bullets through the opening of 
entrance may be made by aid of spoon 
or forceps-shaped instruments. Bullet- 
forceps with long, thin blades are often 
difficult to use, because they cannot be 
sufficiently opened in the narrow canal 
to seize the bullet, hence many military 
surgeons prefer the spoon-shaped instru- 
ment. Such a bullet scoop has lately 
been suggested by B. v. Langenbeck, 
and seems very practical ; in it the 
spoon is movable so as to pass behind 
the bullet, and push it forward. Still better, it seems to me, is a 
recently-invented American forceps, whose peculiarity is that they 
can be opened even in a narrow canal, and they seize very securely. 
If the bullet be lodged in a bone, we may bore a long gimlet into it, 




Bullet-forceps, made by Geo. Tiemann 
& Co., of New York, with sharp 
points for seizing leaden bullets. 






TREATMENT OF GUNSHOT-WOUNDS. 263 

and try to extract it in that way. If we do not succeed in removing 
the bullet or other foreign body by the opening of entrance, we proceed 
to enlarge it to gain more room so as to apply the instruments better. 
The experience that bullets may often remain in the body without in- 
jury should warn us against any violent operation that aims only at 
their extraction. Hence, haemorrhage and difficult extraction of for- 
eign bodies are the chief indications for primary dilatation of gunshot- 
wounds. Later, other indications may arise to necessitate it ; but, in 
the gunshot-wound, such enlargement is not necessary for a cure. This 
takes place by the throwing off of a small ring-shaped eschar, and the 
detachment of gangrenous shreds from the track of the wound, till 
healthy granulation and suppuration begin, and the canal gradually 
closes from within outward. In most cases the opening of exit 
cicatrizes before the entrance. Certain obstacles may stand in the 
way of this normal course ; there may be deep progressive inflamma- 
tions, rendering necessary new incisions and the employment of ice, 
as in other deep contused wounds. 

The first dressing of a gunshot-wound in the field is usually a 
moist compress, covered with a bit of oiled muslin or parchment- 
paper, held in place by a bandage or cloth. Frequently nothing 
further is required than simply keeping the wound moist and covered 
with charpie, lotions of lead-water, chlorine-water, etc. As yet there 
are no full observations of the treatment of gunshot-wounds without 
dressings. They occasionally, though rarely, heal by first intention ; 
as a rule, they suppurate for a longer or shorter period. One of the 
chief causes of deep inflammation is the presence of foreign bodies, 
such as bits of clothing, leather, etc. The presence of the bullet, or 
a portion of it, is far less dangerous, for the cicatricial tissue may 
grow around and entirely encapsulate the lead, while the wound 
closes over it; the patient keeps the bullet in him. But these bullets 
do not always remain in the same spot ; they partly sink, from their 
weight, partly are displaced, by muscular action, so that after years 
they are found at different (generally lower) points : for instance, a 
bullet may enter the thigh, and subsequently, after being almost for- 
gotten, may be felt under the skin of the calf or heel, and may thence 
be readily extracted. I have told you the same thing about needles. 
But non-metallic bodies seem never able to remain thus without 
injury in the human body, and hence should always be extracted 
when discovered in a wound. 

In gunshot-wounds the fever generally depends on their size and 
extent, as well as on the accidental suppuration. In the excellently- 
directed hospital of the Bavarian chief staff-surgeon J3eck, which I 
visited at Tauberbischofsheim (1866), the thermometer was used for 



264 



GUNSHOT-WOUNDS. 



determining the amount of fever ; the results as to fever generally 
correspond with those in other injuries. 

[Demarquay (quoted in the Medical Times and Gazette, Septem- 
ber, 1871) says that in all cases observed, where the temperature fell 
below 95° Fahr., the patients died.] 

The special rules to be observed in perforating wounds of the 
skull, thorax, and abdomen, are given in special surgery ; let us here 
make a few remarks on the fractures resulting from gunshot-wounds. 
We have already stated that simple subcutaneous fractures occur from 
spent or obliquely-falling bullets ; but, in most cases, the fractures are 
accompanied by wounds of the soft parts. The soft, spongy bones 
and the epiphyses may be simply perforated by bullets without any 
splintering. This injury is comparatively favorable ; if the adjacent 
joint be not opened, the bullet may remain in the bone, and, if it 
cannot be extracted, may heal there ; the track of the wound in the 
bone suppurates, fills with granulations, which at least partly ossify, 
so that the firmness of the bone is not impaired. If the bullet strikes 

Fig. 60. 





Femur of a French soldier, broken 
by a needle-gun bullet. 



Tibia of a German soldier struck 
by a chassepot-projectile. 



TREATMENT OF GUNSHOT-WOUx\ T DS. 265 

the diaphysis of a long bone, it generally splinters it, and does so 
much more extensively than any other cause. The numbers of sharp 
splinters, and the extent of the splintering in proportion to the diame* 
ter of the projectile, is the most noticeable feature that we observe 
when first seeing a large number of gunshot- wounds. 

I think it is necessary and very important to examine every gun- 
shot-wound of the extremities with the finger quite early, and to 
remove fragments that are loose or slightly attached to the soft parts ; 
it may be advisable now and then to cut or saw off pointed frag- 
ments where it can be done without much new injury or extensive 
incisions through the soft parts. But I would not recommend these 
resections in the continuity as a usual or necessary operation, for ex- 
perience shows that many such cases go on favorably without opera- 
tions. 

If the injury has caused a complicated fracture in a joint, we can- 
not hope for much from an expectant treatment, according to present 
experience, which is based on statistics ; the question rather seems to 
be, whether primary resection or amputation is preferable ; this can 
only be decided by the peculiarities of each case. 

Lastly, we must mention that secondary haemorrhages are par- 
ticularly frequent in gunshot as in other contused wounds. 

I consider the treatment of gunshot-fractures, by fenestrated plas- 
ter-bandages, as the only proper method (excepting perhaps those in the 
upper part of the arm or thigh) ; the only thing against it is, that 
surgeons who have not already treated open fractures with plaster- 
dressings, and are not adepts in the application, should not make their 
first experiments on gunshot-fractures, but should only apply dressings 
with which they are familiar. 

Secondary suppurative inflammations occur in gunshot-wounds 
even more frequently than in other contused wounds; the same 
causes that we have already learned for these dangerous accidents, 
unfortunately often act in gunshot-wounds also. 

We must satisfy ourselves with these few remarks on the subject 
of gunshot-wounds, glad as I should be to continue the subject. Those 
who feel special interest in the subject, I refer to the works already 
mentioned, and to a little book of my own, " Historical Studies on 
the Consideration and Treatment of Gunshot- Wounds," in which you 
will find the old literature brought together. 



CHAPTER IX. 
BURNS AND FBO S T-BITES. 



LECTURE XX. 

I Burns : Grade, Extent, Treatment.— Sunstroke. — Stroke of Lightning. — 2. Frost- 
bites : Grade. — General Freezing, Treatment. — Chilblains. 

The symptoms due to burns and frost-bites are quite similar, but 
are sufficiently distinct to be regarded separately ; we shall first treat of 

BUENS. 
These are caused by the flames, when, for instance, the clothes burn, 
but more frequently by hot fluids, as when children pull vessels of hot 
water, coffee, soup, etc., off a table on to themselves. And, unfor- 
tunately, in factories, barns from hot metals, such as molten lead, iron, 
etc., are not rare, and in every-day life slighter burns from matches, 
sealing-wax, etc., often occur, as you have all doubtless seen. Besides 
the above, concentrated acids and caustic alkalies not unfrequently 
cause burns of various degrees, analogous to those from hot bodies. 

In burns the intensity and extent of the injury are to be regarded ; 
we shall hereafter study the latter. The intensity of the burn de- 
pends essentially on the grade of the heat and the duration of its 
action ; according to the result of this action, burns have been divided 
into three grades. These pass into one another, but from the accom- 
panying symptoms may be distinguished without difficulty; the only ob- 
ject of this is to render explanation easier. We assume three grades. 

First degree (hyperemia) : The skin is much reddened, very painful, 
and slightly swollen. These symptoms are due to dilatation of the 
capillaries, and slight exudation of serum in the tissue of the cutis. 
There is a mild grade of inflammation, in which there is an increase 
of cells in the rete Malpighii alone, which is followed, in many cases 
at least, by detachment of the epidermis. Redness and pair occasion- 



DEGREES OF BURNS. 267 

ally last a few hours, in other cases several days. But it is not neces- 
sary, and not at all practical, to make several grades on this account. 

Second degree (formation of vesicles) : Besides the symptoms of 
the first degree, vesicles arise on the surface of the skin ; before burst- 
ing these contain serum, clear or mixed with a little blood. These 
vesicles form immediately, or in a few hours after the reception of the 
burn, and may vary greatly in size. Anatomically we find that in 
most of these cases the horny layer is detached from the mucous layer 
of the epidermis, so that the fluid rapidly escaping from the capilla- 
ries lies between these two layers, just as results from the action of a 
blister. The vesicles rupture or are punctured ; from the remaining 
rete Malpighii a new horny layer of the epidermis forms quickly, and 
in six or eight days the skin is the same as before. It may also hap- 
pen that after removal of the vesicle the denuded portion of skin is 
excessively painful, and for several days, or even a fortnight, there may 
be superficial suppuration ; the pus finally dries to a scab, under which 
the new epidermis forms. You may induce this state also artificially 
by leaving a blister for a long time on one spot. Here also it is un- 
necessary to make new grades of these variations, for they only de- 
pend on a little greater or less destruction of the rete Malpighii, 
while the greater or less pain corresponds to the amount of denuda- 
tion of the nerves in the papillae of the skin. 

Third degree (formation of eschars) : By this term we may desig- 
nate all those cases where there is formation of eschars, i. e., where 
portions of the skin, and even of the deeper soft parts, are destroyed 
by the burn. Of course, the varieties may be very great, as in one 
case there may be only burning and charring of the epidermis and 
papillae, in another death of a portion of the cutis, in a third charring 
of the skin or of an entire limb. In all cases where the papillary layer, 
with the rete Malpighii, is destroyed, there will be more or less sup- 
puration, by which the mortified portion will be detached, which of 
course will leave a granulating wound, that will follow the ordinary 
course in healing. If only the epidermis and the surface of the pa- 
pillae be charred, there is only slight suppuration, with rapid replace- 
ment of the epidermic layer from the remains of the rete Malpighii. 

From what has been said, you may understand how from four to 
seven or more degrees might be formed ; but, to make the subject com- 
prehensible, the three degrees of redness, vesicles, and eschars, are 
enough. In extensive burns we often find these different degrees 
combined, and, when the injured part is covered with charred epider- 
mis and dirt, it is often difficult to determine the degree at any point. 
If there be suppuration, it may be either superficial or deep ; occasion- 
ally it appears as if islands of young cicatricial tissue formed in the 



268 BURNS AND FROST-BITES. 

midst of a granulating wound, and this has given rise to the false idea 
that the latter could cicatrize not only from the edges but from differ- 
ent points in the midst of the wound. But such cicatricial islands 
never form where there is total absence of the papillary bodies of the 
skin, but only from some remnants of the rete Malpighii, as may hap- 
pen in burns and certain ulcerations to be hereafter mentioned. 

The prognosis for the function of burnt parts may be inferred from 
what has been said. We should, however, add that after extensive loss 
of the skin, as occurs especially from burns of the neck and upper ex- 
tremities by hot liquids, there is very considerable cicatricial contrac- 
tion, by which, for instance, the head may be completely drawn to one 
side of the neck, or anteriorly to the sternum, or the arm fixed in a 
flexed position by a cicatrix in the bend of the elbow. In the course 
of time these cicatrices become more distensible and pliable, but rarely 
to such an extent as entirely to remove the disturbance of function 
and the disfigurement, so that in many cases plastic operations are 
necessary to improve these conditions. It was formerly asserted that 
the cicatrices after burns contracted more strongly than any other 
cicatrices. But this is only apparently so, for scarcely any other in- 
jury ever causes the loss of such large portions of skin ; we may 
readily perceive that, when this does occur (as in plastic operations 
and after extensive destruction of the skin by ulcerations), the con- 
traction of the cicatrix is just as great. 

Entirely apart from the different degrees of burns, their extent is 
of the greatest importance, as regards their danger to life. It is gen- 
erally said that, if two-thirds of the surface of the body be burned 
only in the first degree, death soon occurs, in a manner that has as 
yet received no physiological explanation. Persons thus injured fall 
into a state of collapse, with small pulse, abnormally low temperature, 
and dyspnoea, and die in a few hours or days. In other cases life 
lasts somewhat longer ; death occasionally results from severe diar- 
rhoea, with the formation of ulcers in the duodenum, near the pylorus, 
a complication which also sometimes comes in septicaemia. The rapid 
occurrence of death from extensive burns has received various ex- 
planations : first, it was asserted that simultaneous irritation of almost 
all the peripheral nerve-terminations in the skin was too great an irri- 
tant for the central nervous system, and hence caused paralysis ; then 
that the cutaneous perspiration was arrested, and death was to be ex- 
plained here, as in the case of animals, whose whole body has been 
covered with an air-tight layer of oil-paint, caoutchouc, or pitch. In 
the latter hypothesis it is assumed that the excretion by the skin of 
certain substances, especially of ammonia, is interfered with by the 
impermeable coating (as by the burning of the skin), and that a fatal 



TREATMENT OF BURNS. 269 

blood-poisoning is thus induced. Lastly, the symptoms might be the 
result of an intense phlogistic or septic (where there is formation of 
eschars) intoxication. Should the burn not prove fatal from its extent 
alone, the great loss of skin and consequent suppuration may prove 
dangerous, especially for children and old persons ; in the same way 
the amputations necessary from complete charring of single extremi- 
ties involve certain dangers, which are the more serious as they affect 
persons already greatly depressed by the burn. 

In the treatment of burns in the first and second degrees, more 
depends on alleviating the pain than on any energetic treatment ; for 
we cannot hasten the return of the skin to its natural state, but must 
leave the course of healing entirely to Nature. If there are any vesi- 
cles, it is not advisable to remove the loosened epidermis, but to open 
the vesicle by a couple of needle-punctures, and carefully press out the 
serum, to relieve the tense feeling. It would be most natural to cool 
the burnt part, by applying cold compresses, or holding it in cold 
water. But this is not usually very popular with patients, as the cold 
should be considerable and continued, to relieve the pain very much. 
The cold-water compresses warm too quickly, and immersion in cold 
water is only applicable to the extremities, hence cold is compara- 
tively little used in burns. Numerous remedies are used in burns, 
whose only effect is to perfectly cover the inflamed skin. Smearing 
the surface with oil and applying wadding is a very common and pop- 
ular treatment. Mashed potatoes, starch, and collodion, are also much 
used as protective coverings for the burned skin. The two former may 
be regarded as popular remedies ; for extensive burns I cannot praise 
collodion very much ; the collodion covering cracks readily, and in the 
cracks the skin becomes sore and very sensitive. Some surgeons use 
peculiar salves and liniments instead of oil ; such as a liniment of 
equal parts of lime-water and linseed-oil, salve of equal parts of butter 
and wax, lard, rind of bacon, etc. Another plan of treatment is with 
a solution of nitrate of silver, ten grains to the ounce of water ; this 
is to be painted over the burnt part, and compresses wet with the 
same to be kept constantly applied. At first the pain from the cau- 
terization of the parts denuded of epidermis is occasionally very great, 
but a thin blackish-brown crust soon forms, and the pain then ceases 
entirely. I particularly recommend to you this plan of treatment 
when all three degrees of burns are combined. 

In burns of the third degree, if there is only mortification of the 
cutis (when this is not charred, but burned by boiling water, it gen- 
erally becomes perfectly white), the treatment is the same as that 
above given. Should it subsequently be desirable to hasten the de- 
tachment of the eschar, cataplasms may be employed to stimulate 



270 BURNS AND FROST-BITES. 

suppuration ; in most cases, however, this will be unnecessary, and 
the treatment by nitrate of silver may be continued till the eschar is 
completely detached. If large granulating surfaces remain, especially 
on parts of the surface that are moved much, and where the neigh- 
boring skin is not very movable, it may take a long time, often months, 
for them to heal. Very luxuriant granulations form, and their ten- 
dency to cicatrize is always very slight. Of the remedies already 
given for promoting the healing of such wounds, I particularly recom- 
mend to you the compression of the wound by strips of adhesive 
plaster, which are of excellent service in some of these cases. In the 
treatment of cicatricial contractions resulting from these burns, com- 
pression of the cicatricial bands by adhesive plaster is one of the most 
important remedies, and you would always do well to try this per- 
sistently before resorting to excision of the cicatrix, or to plastic 
operations. 

If, in a burn of the third degree, there has been charring of a 
limb, it may often be advisable to amputate at once ; not only because 
the detachment of a large part of the body is not free from danger, 
but also because the stumps thus left are unfit for the application of 
an artificial limb. 

If called to a case where there is a burn of the greater part of the 
body, you must give your whole attention to the general condition of 
the patient, and try to prevent collapse, by the use of stimulants, such 
as wine, hot drinks, hot baths, ether, ammonia, etc. Unfortunately, 
in most of these cases, our efforts to preserve life are in vain. Hebra 
praises the treatment of extensive burns by the continued warm bath, 
which, under proper circumstances, may be kept up for weeks. 



Persons with delicate skins, long exposed to the sun's rays, may 
have slight degrees of burns of the face and neck. This is often ob- 
served in persons travelling on the mountains. When persons, espe- 
cially women, who do not usually pass the day in the sun, travel for 
several bright days in summer, without carefully protecting the face 
and neck, the skin becomes red, swollen, and very painful ; after three 
or four days the skin dries to brown crusts, cracks, and peels off. In 
other persons, with still more irritable skins, vesicles form, which sub- 
sequently dry up, without, however, leaving any cicatrices (eczema 
solare). Besides prophylaxis by veils, sun-shades, etc., it is well to 
cover the skin of such mountain travellers with cold cream or glyce- 
rine ; the same remedies may also be used in developed sunburn ; if 
the burnt parts be very painful, we may apply cold compresses. 

Here we must also speak of sunstroke, or insolation. In our cli- 



FROST-BITES. 271 

mate, this disease occurs almost exclusively in young soldiers, who 
have to make fatiguing marches in full uniform in very hot, bright 
weather. There are severe headache, dizziness, unconsciousness, and 
sometimes death in a few hours. In the Orient, especially in India, 
this disease is not rare among the English soldiers ; some cases are 
quite acute, ending with tetanic spasms ; others begin with long pro- 
dromata, and drag on with symptoms of severe headache, burning 
skin, continued fatigue and depression, palpitation of the heart, 
twitching of the muscles, etc. ; even when this state ends in recovery, 
relapses are common. Patients with sunstroke are to be treated like 
those with congestion of the brain. Cold affusions and bladders of 
ice to the head, rest in a cool chamber, purgatives, leeches behind the 
ears, sinapisms to the nape of the neck, are the proper remedies. Ac- 
cording to the experience of English surgeons, venesection is injuri- 
ous. 



We also have something to say about the effect of being struck 
by lightning. Probably all of you have at some time seen houses or 
trees that had been struck by lightning ; we usually see a large rent, 
a fissure with charred edges. Men and animals may also be struck 
so as to lose single limbs, but this is not always the case ; usually 
the lightning travels along the body, in at one place, out at another ; 
the clothes are rent, or even torn off and cast aside ; peculiar, branched, 
zigzag brownish-red lines are found on the body ; these have been 
regarded as representations of the nearest tree, or as blood coagulated 
in the vessels and shining through ; both views are incorrect ; we do 
not know why the lightning runs this peculiar course on the skin. If 
a person be directly struck by lightning, he is usually killed on the 
spot. If the lightning strike in his immediate vicinity, it induces 
symptoms of commotion of the brain, paralysis of certain limbs or or- 
gans of special sense, and occasional extravasations and burns. The 
latter heal like other burns, according to their degree and extent. 
Paralysis from lightning is not usually of bad prognosis ; the nervous 
and muscular activity may return after a longer or shorter time. 

FEOST-BITES. 

We may aivide frost-bites into three grades analogous to those of 
burns ; the first of these is characterized by redness of the skin, the 
second by formation of vesicles, the third by eschars. The first degree 
of frost-bite is quite well known ; we might regard the so-called dead- 
ness of the fingers as its mildest form ; probably each of you has some- 
time had this in a cold bath, or in winter-time. The finger becomes 



272 



BURNS AND FROST-BITES. 
Fig. 61. 





Traces of lightning (after Strieker). 



white, the skin wrinkled, the sensation diminished ; after a time these 
symptoms pass off, the skin becomes red, the finger swells, and there 
is a peculiar itching and prickling. This increases the more, the more 
quickly warmth follows the cold. The redness of the skin of this 
degree of frost-bite differs from that in burns, by its more bluish-violet 
color. 

After a time, these symptoms subside and the skin again becomes 



FEOST-BITES. 273 

normal. Generally no remedies are used in these slight cases, but, 
very properly, patients are warned against warming the parts too 
rapidly ; rubbing with snow, then gradually elevating the tempera- 
ture, is recommended. The above symptoms are thus explained: 
First, the capillaries are strongly contracted by the cold, and are then 
paralyzed for a time. I shall not here discuss the tenability of this 
hypothesis ; this explanation involves all the difficulties that we have 
already met in the theories of inflammation. 

Redness following a frost-bite may sometimes remain permanent, 
i. e., the capillaries remain dilated. This is especially apt to occur 
in frost-bites of the nose and ears, and is usually incurable. In Ber- 
lin, I treated a young man who had a dark-blue nose, as a result of 
frost-bite, and wished at all hazards to be relieved of the deformity. 
He persistently pursued the different modes of treatment ; first, he had 
the nose painted with collodion, after which it looked as if varnished, 
and, as long as the coating of collodion continued, it was somewhat paler, 
but the improvement was not permanent. Then the nose was painted 
with dilute nitric acid, which gave it a yellow tint. After detachment 
of the epidermis the evil again appeared improved for a time ; but it 
soon returned to its former state. Then we tried treatment with 
tincture of iodine and nitrate of silver, which for a time gave the nose 
a brownish-red, then a brownish-black color. The patient bore all 
these changes of color heroically, but the perverse capillaries continued 
dilated, and the nose remained bluish red at the last, just as it had 
been. I still thought of trying cold, but feared the condition might 
be made worse, and, after several months' treatment, had to tell the 
hero of this tragi-comical history that I could not cure him. The 
treatment of chilblains and the consequent ulcers, of which we shall 
speak immediately, may be just as difficult. , 

Frost-bite, where, besides redness of the skin, there is formation of 
vesicles, is more severe ; it is often accompanied by complete loss of 
sensation of the affected part, and there is always danger of mortifica- 
tion. The formation of vesicles in frost-bite is prognostically much 
worse than it is in burns. The serum contained in the vesicles is 
rarely clear, but usually bloody. A limb completely frozen is said to 
be perfectly stiff and brittle, and small portions are said to break off 
like glass, if carelessly handled. I have had no opportunity to verify 
these statements, but remember that, when I was a student, a man was 
was brought to the Gottingen surgical clinic with both feet frozen ; 
during transportation to the hospital, they had become spontaneously 
detached at the ankle-joint, so that they hung only by a couple of. 
tendons. Double amputation of the leg above the malleoli had to be 
made. How far a limb may be entirely frozen, so that the circulation 
18 



274 BURNS AND FROST-BITES. 

is entirely arrested, frequently cannot be determined for a time; 
hence we must not be too hasty about amputating. In Zurich, I had 
two cases where both feet were dark blue and without feeling, and 
on being punctured with a needle only a drop of black blood escaped ; 
nevertheless, the foot lived, and only a few toes were lost. In a third 
case, in a very debilitated patient, where both feet as high as the 
calf were dark blue and covered with vesicles, they became entirely 
gangrenous. If there be extensive gangrene of the skin, beyond a 
doubt, we should not delay amputating, for these patients are very 
subject to pyaemia. A very sad case occurred in the Zurich hospital. 
A powerful young man had both hands and both feet frozen, so that 
all became gangrenous ; the patient could not make up his mind to the 
four amputations, nor could I bring myself to persuade him to the 
fearful operation. He died of pyaemia. 

The ends of the extremities, the point of the nose, and tips of the 
ears, are most liable to be frozen. Closely-fitting clothes, which impede 
the circulation, increase the predisposition. Cold wind, and cold ac- 
companied by moisture, induce frost-bite more readily than very great 
still, dry cold. 

There is also a total freezing or stiffening of the whole body, in 
which the patient loses consciousness, and falls into a state of very 
limited vitality. The radial pulse can hardly be felt, the heart-beat is 
scarcely audible, the respiration almost imperceptible, and the whole 
body is icy cold. This state may pass at once into death ; then all 
the fluids harden into ice. This general freezing is especially apt to 
occur when the individual, overcome by fatigue and cold, lies down 
while freezing; he soon falls asleep, and sometimes never wakes 
again. It has never been accurately determined how long a patient 
may remain in this stiff condition, with very slight appearance of life, 
and again recover; we find mention of the state having lasted six 
days. Whether this be true or not, we should continue our attempts 
at resuscitation as long as a heart-beat can be detected. 

Let us commence the treatment of frost-bite with this state of 
general stiffness. We must here avoid any sudden change to higher 
temperature, but increase the warmth gradually. Such a patient 
should be placed in a cool chamber, on a cold bed, and frictions made 
for several hours. At the same time, artificial respiration should be 
occasionally tried, if the breathing becomes imperceptible. As slight 
stimulants that may do good, I would mention enemata of cold water, 
md holding ammonia to the nostrils. Very gradually, as the patient 
becomes conscious, we raise the surrounding temperature, keep him for 
a time in a slightly-warmed room, and at first give only tepid drinks. 
As the differ/ mt parts of the body, one by one, regain vitality, there is 



TREATMENT OF FROST-BITE. 275 

occasionally some pain in the limbs, especially if they v, ere warmed 
too rapidly ; in these cases it is well to envelop the painful parts in 
cloths dipped in cold water. The patient may remain for hours or 
days in a benumbed, senseless condition, which disappears gradually 
Of late, experiments have been made in resuscitating stiffened ani« 
mals, which appear to show that animals are more certainly saved 
from death by rapid than by slow warming. I should not readily de- 
cide, from these experiments on animals, to depart from the rules 
already empirically employed for treatment of persons frozen stiff, and 
which appear to be correct for local frost-bites, but the question is 
worth further experiment. Such cases of general freezing rarely 
escape without loss of some limbs, or parts of them, and, in regard to 
the treatment of these frozen parts, I can give you little advice. The 
vesicles are punctured and evacuated; the feet or hands may be 
wrapped in cold, wet cloths ; then we must wait to see whether and 
how extensively gangrene will occur. If the bluish-red color passes 
into a dark cherry-red, the chances of restoration to life are slight. 
Gangrene will occur in the great majority of such cases. By testing 
the sensibility with a needle, and noting the escape of blood from 
these fine openings, we test how far the limb has ceased to live ; but 
this only becomes certain when the line of demarkation forms ; that 
is, when the dead is sharply bounded from the living, and inflamma- 
tory redness develops on the border of the gangrenous parts. But 
the general condition may become dangerous before the line of de- 
markation is fully formed ; hence amputation must not be delayed 
too long if the inflammation after freezing assumes a phlegmonous 
character. The detachment of single toes or fingers we may leave 
to itself; but where there is gangrene of a large part of a limb, 
amputation is decidedly preferable. 9 

I will here return to chilblains (perniones), not because they may 
become particularly dangerous, but because they are an exceedingly 
annoying disease, and are in some cases very difficult to cure, and for 
which, as good family doctors, you must have a series of remedies. 
Chilblains are caused by paralysis of the capillaries, with serous exu- 
dation in the tissue of the cutis ; they are, as most of you know, 
bluish-red swellings on the hands and feet, which prove excessively 
annoying from their severe burning and itching, and from the occa- 
sional formation of ulcers. They result from repeated slight freezing 
of the same spot, and do not occur with equal frequency in all per- 
sons ; they are less annoying in very cold weather than during the 
change from cold to warm. At night, on going to bed, when the 
hands and feet become warm, the itching occasionally becomes so 
troublesome that the patient has to scratch them for hours. In gen- 
eral, females are more disposed than males, and young persons more 



276 BURNS AND FROST-BITES. 

than old, to chilblains. Employments requiring frequent change of 
temperature particularly predispose to them ; clerks and apothecaries, 
who stay for a time in a warm room, then in a cold cellar or ware- 
house, are frequent subjects. But no station is exempt ; people who 
always wear gloves, and rarely go out in winter, may be attacked as 
well as those who have never worn gloves. Among females, chlorosis 
and disturbances of menstruation occasionally seem to predispose to 
them ; generally, frequent returns of frost-bite appear to be connected 
with some constitutional anomaly. 

As regards treatment, it is usually very difficult to combat the 
causes due to constitution aod occupation ; hence we are chiefly lim- 
ited to local remedies. In Italy, where the disease is very frequent, 
if a cold winter occurs, frictions with snow and ice compresses are 
recommended. With us, these are less used, and do no good, or at 
most only alleviate the itching for a time. Salve of white precipitate 
of mercury (one drachm to the ounce of lard), frictions with fresh 
lemon-juice, painting with nitric acid diluted with cinnamon-water (one 
drachm to four ounces), solution of nitrate of silver (ten grains to the 
ounce), and tincture of cantharides, are remedies that you may resort 
to. Sometimes one answers, sometimes another ; hand or foot baths 
with muriatic acid (about one and a half to two ounces to a foot-bath, 
use for ten minutes), and washing with infusion of mustard-seed, are 
also celebrated. If the chilblains open on the top, they may be 
dressed with ointment of zinc or nitrate of silver (gr. j to 3 j fat). I 
have here given you only a small number of the remedies recom- 
mended, the effect of most of which I have myself proved, although 
there are a number of others ; at the commencement of your practice 
you will find these enough for combating this common, trifling disease, 



CHAPTER X. 

ACUTE NON-TRAUMATIC INFLAMMATION OF THE 
SOFT PARTS. 



LECTURE XXI. 



General Etiology of Acute Inflammations. — Acute Inflammation: 1. Of the Cutis. 
a, Erysipelatous Inflammation ; &, Furuncle ; c, Carbuncle (anthrax), Pustula Ma- 
ligna. 2. Of the Mucous Membranes. 3. Of the Cellular Tissue, Acute Abscesses. 
4. Of the Muscles. 5. Of the Serous Membranes, Sheaths of the Tendons, and 
Subcutaneous Mucous Bursse. 

Gentlemen: So far we have treated only of injuries, now we 
shall pass to the acute inflammations which are of non-traumatic 
origin. Of these cases, those belong to surgery that occur on the 
outer part of the body ; also those which, occurring in internal organs, 
are still accessible to surgical treatment. Although I must start with 
the idea that you already know the causes of disease in general, it 
still seems necessary to make some preliminary remarks with special 
reference to the subject of which we are about to treat. 

The causes of acute non-traumatic inflammations may be divided 
into about the following categories : 

1. Repeated Mechanical or Chemical Irritation. — At the first 
glance, this seems to come under the head of trauma, but it makes 
considerable difference whether such an irritation acts once on a tissue 
or whether it be frequently repeated, for, in the latter case, each suc- 
ceeding irritation affects a tissue already irritated. An example will 
make this clear to you. Suppose a person is rubbed continuously by 
a projecting sharp nail in his boot or shoe ; at first there would be a 
slight wound with circumscribed inflammation, but afterward the 
inflammation will spread and become more intense as long as the irri- 
tation lasts. Let us take another example of chemical irritation : If 
a person not accustomed to highly-seasoned food eats Spanish pepper 



278 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

it would induce temporary hyperemia and swelling of the oral and 
gastric mucous membrane ; should one continue the use of so acrid a 
substance for a length of time, he might excite a severe gastritis. 
Except in cases of the first example, these rapidly-repeated irritations 
are not frequent in practice, but they have a great deal to do with the 
origin of chronic inflammation ; when, of themselves insignificant, they 
act on parts more or less weak. We must again return to this 
point. 

2. Catching Cold. — You all know that by catching cold one may 
acquire various diseases, especially acute catarrh and inflammations of 
the joints or lungs ; but we do not know what is the particular inju- 
rious influence in catching cold, or what immediate changes it causes 
in the tissues. The rapid change of temperature is blamed as the 
chief cause of catching cold, but by this means we cannot experi- 
mentally induce an inflammation, or any similar disease. One catches 
cold from being heated, and then being exposed to a cold draught for 
a length of time ; by careful observation he may say just when he 
caught cold. The cold may have a purely local action ; for instance, 
one sits for a time at the window, and the cold wind blows on the side 
of his face toward the window ; after a few hours he is attacked by 
paralysis of the facial nerve. We may here assume that molecular 
changes have occurred in the nerve-substance, by which the conduct- 
ing power of the nerve is lost. Another might get a conjunctivitis 
from the same cause. These are purely local colds. Another case is 
more frequent, viz., that on catching cold that part is attacked which 
in the person affected is most liable to disease, the "locus minoris 
I'esistentice." Some persons, after catching cold in any way, have 
acute catarrh of the nose (snuffles) ; others have gastric catarrh, others 
muscular pains, and still others have inflammations of the joints. 
Now, as these parts are not always directly affected by the injury (as 
when one has nasal catarrh from getting his feet wet), we must sup- 
pose that the whole body is implicated, but the action of the injury is 
only shown at the locus minoris resistentice. Whether this transfer 
of such injurious influences to a special part of the body is due to the 
nerves, or to the blood and other fluids of the body, is a question which 
cannot at present be decided, and about which physicians are divided 
into the two great bodies of neuropaths and humoralists. Reasons 
may be adduced for both views. I rather incline to the humoral view, 
and regard it as possible that, for instance, chemical changes may 
occur or be prevented in the skin while sweating, which may have a 
poisonous effect on the blood, and may act as an irritant now on this, 
now on that organ. According to the old form of speech, these in- 
flammations due to catching cold are called " rheumatic " (from pevfia, 



MIASMATIC INFECTION. 279 

flow) ; but this expression is so much misused, and has come into such 
disrepute, that it should not be employed too often. 

3. Toxic and Miasmatic Infection. — We have already (page 
167) stated that moist and dry, purulent and putrid, substances 
brought in contact with a wound induce severe progressive inflamma- 
tions, if they enter the healthy tissue immediately after the injury or, 
under certain previously-mentioned circumstances, pass through the 
granulations of a wound into the tissue. It is true, the body is 
tolerably protected on its surface by the epidermis, on the mucous 
coats by thick epithelium, against the entrance of such poisonous and 
inflammatory materials, but the protection is not perfect. There are 
many poisonous substances which enter the body through the skin or 
mucous membrane. Some of them we term poison, such as the secre- 
tion from glander-ulcers in the horse, or from the carbunculous pus- 
tules in cattle ; others we only know from their effects, from some 
circumstances of their origin. There are invisible bodies which we 
term " miasmatic poisons," or briefly " miasm " (jjuaofia, uncleanness) ; 
it is supposed that these miasms develop from decomposing organic 
bodies. Some consider them as gases, others as dust-like particles, 
others as minute organisms or their germs ; I think that in many 
cases the latter is the correct view. The action of these poisons 
varies, inasmuch as some of them have a direct phlogistic action ; in 
others it is more indirect. Thus some poisons, as pus, cadaveric 
poison, induce severe inflammation at the point where they enter the 
body (infectionsatrium) / others excite no inflammation at that point, 
but are imperceptibly taken into the blood, and, although circulating 
through all the organs, only have an inflammatory effect on one or a 
few parts of the body. These poisons are, to a certain extent, only 
injurious to certain organs ; they have a " specific " action. I shall 
not here speak of the primary action of this poison in transforming 
the blood. We do not know the chemically active constituents of 
most of these poisons which act specifically on one organ or tissue ; 
we cannot see them circulate, nor can we always see their effects. 
Hence, you may very justly ask me how we can express ourselves 
with so much certainty on the subject. We decide on the causes by 
observing the morbid symptoms, and, in so doing, support ourselves 
mainly on their analogy to the effects of poisons intentionally intro- 
duced into the body, especially to those of our most active medicines. 
If we take the group of narcotics, they all have a more or less be- 
numbing effect, that is, a paralyzing effect, on the psychical functions, 
but they have also the most peculiar specific effects. Belladonna acts 
on the iris, digitalis on the heart, opium on the intestinal canal, etc. 
We see the same thing in other remedies. By repeated doses of can- 



280 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

tkarides we may excite inflammation of the kidneys, by mercury in- 
flammation of the oral mucous membrane and salivary glands, etc., 
whether we introduce them into the blood through the stomach, rec- 
tum, or skin. So also there is an endless number of known and 
unknown organic septic poisons, of which many, if not all, have also 
a specific phlogogenous action. I mention only one example : if you 
inject putrid fluid into the blood of a dog, in many cases, besides the 
direct blood intoxication, he will have enteritis, pleuritis, or pericar- 
ditis. Must we not here suppose that the injected fluid contains one 
or more matters which have a specific inflammatory effect on the 
intestinal mucous membrane, on the pleura and pericardium ? If we 
know the point of entrance of the poison, and have some experience 
of the poison itself, there will rarely be much doubt about the cause 
and action. But how many cases there may be where neither exists ! 
I believe that infection is a much more frequent source of inflamma- 
tions, especially in surgery, than has hitherto been suspected. 



I would still make a few general remarks about the forms ana 
course of non-traumatic inflammations. I have already told you that 
the characteristic of traumatic inflammations is, that they are limited 
to the wounded part ; if they become progressive, it is generally 
through mechanical or toxic (septic) irritation. This would imply 
that inflammations induced by mechanical irritations and toxic actions 
have a tendency to progress, or at least to diffuseness ; this is true of 
most inflammations resulting from catching cold, which attack either 
a whole organ or a large section of one part of the body. In this 
regard, much depends on the intensity of the mechanical irritation, 
and, in toxic inflammations, on the quality and quantity of the poison, 
especially on its more or less intense fermenting action on the fluids 
permeating the tissues. As regards inflammations due to repeated 
mechanical irritation and catching cold, we do not always have reason 
to suppose that their products are more irritating than those of simple 
traumatic inflammation ; but if, during the latter, the affected part 
be kept absolutely quiet, and the lymphatic vessels and interstices 
between the tissues are closed by the infiltration of the parts about 
the wound, the extension of the products of inflammation into the 
surrounding parts is much interfered with. But in repeated mechan- 
ical irritations the tissue is not kept at rest, and consequently the 
products of inflammation extend unimpeded around the irritated part, 
and excite new inflammation. In inflammation due to catching cold, 
according to my humoral view, the materia peccans is poured/ to a 
whole organ or tissue ; hence, these inflammations are mostly diffuse 



ACUTE INFLAMMATION OF THE CUTIS. 281 

from the commencement. If, from an existing point of inflammation, 
a phlogogenous material enter the blood, and thence specifically affect 
any other organ, we call this secondary inflammation " metastatic." 
But these metastatic inflammations may occur in another and much 
more evident manner, by means of a blood-clot in the veins, as we 
shall show in the section on thrombosis, embolism, and phlebitis. 
Non-traumatic inflammations may terminate in resolution, in firm 
organization of the inflammatory product, in suppuration, or in morti- 
fication. But we will now cease treating this subject in general 
terms, and pass to the inflammations of the different tissues. 



1. ACUTE INFLAMMATION OF THE CUTIS. 

The simple forms of acute inflammation of the skin (spots, wheals, 
papules, vesicles, pustules), which are grouped under the common 
name of " acute exanthemata," belong to internal medicine. Only 
erysipelatous inflammation, furuncle, and carbuncle, are generally 
spoken of as true primary inflammations of the cutis. I will here 
remind you that very frequently the skin is secondarily affected, from 
inflammation of the subcutaneous cellular tissue and muscles, or even 
of the periosteum or bones. 

(a.) Erysipelatous inflammation is located chiefly in the papillary 
layer and in the rete Malpighii. The local symptoms are great red- 
ness and oedematous swelling of the skin, pain on being touched, and 
subsequent detachment of epidermis ; these are occasionally accom- 
panied by very high fever, out of proportion to the extent of the local 
affection. The disease lasts from one day to three or four weeks. 
Any part of the skin or mucous membranes may be attacked, but 
idiopathic erysipelas is particularly frequent in the head and face 
Like the acute exanthemata of the skin, according to the views cl 
many pathologists, erysipelas of the head and face should also be re- 
garded as a symptomatic cutaneous inflammation ; that is, that the 
local affection was only one symptom of an acute general disease. In 
that case, surgery would have as little to do with erysipelas as with 
scarlatina, measles, etc. ; but, as it occurs especially in wounded per- 
sons, and particularly often around wounds, we must study it more 
attentively. I consider erysipelas traumaticum not as a symptomatic 
inflammation of the skin, but as a capillary lymphangitis of the skin, 
which is always due to infection. We shall treat of this disease more 
closely among the accidental traumatic diseases, and content ourselves 
here with having called attention to its relationship. 

(b.) The furuncle or phlegmon is a peculiar form of inflammation 
of the skin, usually of typical course. Some of you may know it 



282 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

from personal observation. First, a nodule as large as a pea or bean 
forms in the skin ; it is red and rather sensitive. Soon a small white 
point forms at its apex, the swelling spreads around this centre, and 
usually attains about the size of a dollar ; sometimes the furuncle re- 
mains quite small, about the size of a cherry ; the larger it is, the 
more painful it becomes, and it may render irritable persons quite 
feverish. If we let it run its own course, toward the fifth day the 
central, white point, becomes loosened in the shape of a plug, and pus 
mixed with blood and detached shreds of tissue is evacuated ; three 
or four days later suppuration ceases, the swelling and redness gradu- 
ally disappear, and finally only a punctate, scarcely-visible cicatrix 
remains. 

We rarely have the opportunity of anatomically examining such 
furuncles in their first stage, as they are not a fatal disease ; but, from 
what we see of the development and from incision, the death of a 
small portion of skin (perhaps of a cutaneous gland) seems to be the 
starting-point and centre of an inflammation, during which the blood 
finally stagnates in the dilated capillaries ; by infiltration with plastic 
matter, the tissue of the cutis partly turns to pus, partly becomes 
gangrenous. The peculiarity in all this is, that such a point of in- 
flammation should, as a general rule, show no tendency to spread, but 
should throughout remain circumscribed, and terminate with the de- 
tachment of the little plug above mentioned. 

There is no doubt that in many cases the cause of single furuncles 
is purely local. Some parts where the secretion of the cutaneous 
glands is particularly strong, as the perinseum, axilla, etc., are espe- 
cially predisposed to furuncles ; they are also particularly common 
in persons who have very large sebaceous glands and so-called pim- 
ples, maggots, or comedones. But there are also undoubtedly consti- 
tutional conditions, diseases of the blood, which dispose to the forma- 
tion of numerous furuncles on various parts of the body. This morbid 
diathesis is called furunculosis / should it continue long, it may prove 
very exhausting ; the patients grow thin, and are greatly pulled down 
by pain and sleepless nights ; children and weakly old persons may die 
of the disease. It is very popular to refer furuncles to full-blooded- 
ness and fatness ; it is believed that fatty food predisposes to them. 
In my country (Pomerania) they say that persons who suffer much 
from pustules and furuncles have "bad blood." I should very much 
doubt the truth of the supposition that fatty food especially disposes 
to furuncles. You will often find that miserable, atrophic children, and 
emaciated, sickly people, are frequently attacked by furuncle, and, 
although the lack of care of the skin has something to do with this, 
it is not the sole cause. On the other hand, it is also true that well- 






FURUNCLE AND CARBUNCLE. 283 

nourished butchers are often attacked by furuncles ; but this may be 
otherwise explained, for not unfrequently it may be found that in 
them the furuncles are due to poisoning by some animal matter ; we 
should at least always examine for this cause. But I think it is going 
too far to assume that every furuncle is caused by infection, and is 
always to be regarded as one symptom of a general suppurative dia- 
thesis — of a pyaemia. 

The treatment of individual furuncles is very simple. Attempts 
have been made to cut short the process, and prevent suppuration, by 
early applications of ice. But this rarely succeeds, and is a very tire- 
some treatment, which is not often popular with the patient. I prefer 
hastening suppuration by warm, moist compresses, and, if the furuncle 
does not spread too much, to quietly await the detachment of the 
central plug, then to squeeze out the furuncle, and do nothing more. 
If the furuncle be very large and painful, we may make one incision, or 
two crossing each other, through the tumor ; then the natural course 
of the process is favored by the escape of blood, and the more rapid 
suppuration. 

General furunculosis is a difficult disease to treat successfully, es- 
pecially if we know little of its cause. Usually we give quinine, 
mineral acids, and iron, internally. Besides these, warm baths con- 
tinued perse veringly are to be recommended. A perfectly -regulated 
diet, especially nutritious meats with good wine, is also advisable. 
The individual furuncles are to be treated as above advised. 

(c.) Carbuncle and carbunculous inflammation {anthrax) anatom- 
ically resembles a group of several furuncles lying close together. 
The whole process is more extensive and intense, more inclined to 
progress, so that other parts may be affected by the extension of the in- 
flammation. Many carbuncles, like most boils, are originally a purely 
local disease. Their chief seat is the hard skin of the back, especially 
in elderly persons. Their origin and first stage are the same as in 
furuncle. But soon a number of white points form near each other, 
and the swelling, redness, and pain, in the periphery, increase in 
some cases so much that the carbuncle may attain the size of a soup- 
dish ; and, while the detachment of the white plugs of skin goes on 
in the centre, the process not unfrequently extends in the periphery. 
The detachment of gangrenous shreds is much greater in carbuncle 
than in furuncle. After the loss of the plugs of cutis, the skin ap- 
pears perforated like a sieve, but subsequently not unfrequently sup- 
purates, so that after a carbuncle a large cicatrix is always left. But, 
even when most intense, the process is almost always limited to the 
skin and subcutaneous cellular tissue ; it is most rare for fasciae and 
muscles to be destroyed, so that, w T hen a large carbuncle is in the 



284 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

vicinity of an artery, the danger of destruction of the arterial walls 
is more apparent than real, as is shown by experience. 10 After the ex- 
tensive throwing off of the cellular tissue, and the final arrest of the 
process in the periphery, healthy and usually very luxuriant granula- 
tions develop ; healing goes on in the usual manner, and is accom- 
plished in a time corresponding to the size of the granulating surface. 

You will have already noticed that the process of formation of 
furuncles and carbuncles differs from the inflammations with which 
you are already acquainted, by the constant and peculiar death 
of portions of skin ; and I have mentioned that this gangrene of the 
skin, at first very small, is the primary and local cause of furuncles 
and carbuncles. Of course, this must be induced by an early, per- 
haps primary, occlusion of small arteries, possibly of the vascular 
net-work around the sebaceous glands, without our knowing on what 
final cause this latter depends. 

The course of the ordinary carbuncle on the back is tedious and 
painful, although it rarely causes death. But there are cases, especially 
when the carbuncle or a diffuse carbunculous inflammation occurs in 
the face or head, which are accompanied by high fever and septic or, 
as was formerly said, " typhous " symptoms, and which prove danger- 
ous and are even generally fatal (carbunculus maligna, pustula malig- 
na). All carbuncles of the face are not of this malignant character; 
some run the usual course, and only leave a disfiguring cicatrix ; but, 
as it is difficult and often impossible to tell how the case will turn 
out, I would advise you always to be very careful about the progno- 
sis. Unfortunately, I have had such sad experience in these carbun- 
cles of the face, that in any affection of the kind I am very solicitous 
about the life of the patient. Let me briefly narrate a case or two. 
In a young, strong, healthy man, on a journey to Berlin, from some 
unknown cause a painful swelling began in the lower lip ; it increased 
rapidly, and soon spread to the whole lip, while the patient became 
very feverish. The surgeon who was called applied cataplasms, and 
apparently undervalued the condition of the patient, as he did not see 
him for two days. The third day the face was greatly swollen and 
the patient had a severe chill, and was quite delirious when brought 
to the clinic. I found the lip dark bluish-red with numerous white gan- 
grenous patches in the skin. Several incisions were made at once, the 
wounds were dressed with chlorine-water, cataplasms applied, and a 
bladder of ice placed on the head, as meningitis was beginning. As 
soon as I saw the patient, I declared his condition hopeless ; he soon 
fell into a deep stupor, and died twenty-four hours later, four days 
after the commencement of the carbuncle on the lower lip. Unfor- 
tunately, an autopsy was refused. I will mention another case : A 



CARBUNCLE. 285 

student in Zurich received a sword-cut on the left side of the head. 
The wound healed without any remarkable symptoms ; but it was a 
long while before it closed entirely. For some time there was a 
small, open wound, which was so slight that the patient paid no at- 
tention to it. Violent straining while fencing, and perhaps subse- 
quently catching cold, may have been the causes of the following 
catastrophe. One morning the young man awakened with consid- 
erable pain in the cicatrix, and a general feeling of illness ; a rosy 
redness and moderate swelling of the scalp rendered an attack of 
simple erysipelas capitis probable. But the fever increased in an 
unusual manner, without the redness spreading over the head. The 
patient had a chill, and became delirious. When on the third day he 
was brought to the hospital, in the vicinity of the cicatrix I found a 
number of small white spots, which showed me at once that there 
was carbunculous inflammation ; as the patient was entirely uncon- 
scious, and for several reasons there was probably inflammation of the 
meninges of the brain, I had little hope of a cure ; I gave the ne- 
cessary directions, but the next day the patient was dead. The 
autopsy showed various white gangrenous points in the inflamed scalp 
cicatrix ; on seeking further, the neighboring veins were found plugged 
with clots, and along them the cellular tissue was swollen and con- 
tained points of pus. Anteriorly I could follow this condition of the 
veins as far as the orbit, but did not try to follow it farther, not wish- 
ing to injure the eye. After opening the skull, as soon as the brain 
was removed, we found in the left anterior cranial fossa a moderately 
inflamed spot about as large as a dollar ; the disease affected both the 
dura and pia mater, and even entered the brain-substance. There 
was no doubt that the inflammation starting from the cicatrix on the 
head had travelled along a vein into the cellular tissue of the orbit, 
and thence through the optic foramen and superior orbital fissure into 
the skull. 11 

In many cases of malignant carbuncle of the face, on careful ex- 
amination we shall find such an extension of the inflammation to the 
cranial cavity, and consequent disease of the brain. But I must re- 
mind you that the extent of this inflammation as found in the cadaver 
is not at all in proportion to the severity of the constitutional symp- 
toms, so that the latter are by no means fully explained by the post* 
mortem appearances. Indeed, there are cases, and just the most 
quickly fatal ones, where death occurs without our being able to find 
any disease in the brain. Here there is full room for hypothesis ; in 
the rapid, violent course and the quick change of carbunculous in- 
flammation to gangrene we suspect a rapidly-occurring decomposition 
of the blood, of which the carbuncle itself may be either the cause or 



286 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

result. But, as the decomposition of the blood must have its cause, 
it has been supposed that an insect which has alighted on some car- 
rion, or on the nose of a horse with glanders, or a cow with carbun- 
cle, etc., lights soon after on a man and infects him ; you will here- 
after learn that malignant carbuncles result particularly from carbun 
culous cattle. I know of no cases where this has been actually 
observed, but I do not consider it impossible in certain cases ; this 
supposition is supported by the fact that these carbuncles are most 
frequent on parts of the body which are usually exposed. At all 
events, the high fever and fatal blood-infection are mostly results of 
the local disease ; hence, we must suppose that in these carbuncles, 
under circumstances which we do not exactly understand, peculiarly 
intense poisons are formed, whose reabsorption into the blood causes 
death. But the causes of malignant carbuncle are in most cases en- 
tirely obscure. 12 In diabetes mellitus and uraemia carbuncle occurs, 
just as sugar is observed in the urine of persons otherwise healthy, 
who have furuncles and carbuncles ; these are enigmatical facts. 13 For- 
tunately, carbuncles are not frequent ; even simple benignant carbun- 
cles are so rare that in the extensive surgical policlinic of Berlin, 
where every year five or six thousand patients presented themselves, 
I only saw a carbuncle once in two years or so. In Zurich also they 
were rare. The diagnosis of ordinary carbuncle is not difficult, espe- 
cially after you have seen one ; diffuse carbunculous inflammation can 
only be recognized after a period of observation ; at first it resembles 
erysipelas. 

The treatment of carbuncle must be very energetic, if we would 
prevent the advance of the disease. As in all inflammations disposed 
to gangrene, numerous incisions should be made early, to permit the 
escape of the decomposed, putrid tissues and fluids. Hence in every 
carbuncle you make large crucial incisions, dividing the whole thick- 
ness of the cutis, and long enough to divide the infected skin clear 
through to the healthy. If this does not suffice, you add a few other 
incisions, especially where from the white points you recognize gan- 
grene of the skin. The bleeding from these incisions is proportion- 
ately slight, as the blood is coagulated in most of the vessels of the 
carbuncle. In the incisions you place charpie wet with chlorine-water, 
and renew it every two or three hours ; over this warm cataplasms 
may be regularly applied to hasten suppuration by the moist warmth. 
If the continued warmth be not well borne, as in carbuncle of the 
neck, where it may induce cerebral congestion, the cataplasms may be 
omitted and the antiseptic dressings continued alone, or even cold 
may be resorted to. If the tissue begins to detach, you daily pick off 
the half-loose tags with the forceps, and so try to keep the wound as 



ACUTE INFLAMMATIONS OF THE MUCOUS MEMBRANES. 287 

clean as possible. Strong granulations will soon appear here and 
there ; finally, the last shreds are detached and a honeycombed granu- 
lating surface is left ; this soon smooths off, and subsequently cica- 
trizes in the usual manner, so that it only requires a little occasional 
stimulation from nitrate of silver, like other granulating surface. In 
malignant carbuncle the local treatment is the same that we have just 
described. For the rapidly-occurring cerebral disease the only thing 
we can do is to apply ice to the head. Internally we usually give 
quinine, acids, and other antiseptic remedies. But I must acknowl- 
edge that the results of this treatment are very slight, for in my own 
experience I do not know a case where it has succeeded in averting 
death when septicaemia was at all developed ; this is the more depress- 
ing, because these malignant carbuncles generally attack young, strong 
individuals. Even if the course be favorable as regards life, there will 
be considerable loss of skin and great disfigurement, especially in car- 
bunculous inflammation of the eyelids or lips, as they are mostly de- 
stroyed by gangrene. Early incision, excision, and burning out of 
the carbuncle, also have little effect on the further course of the dis- 
ease, as I have proved to myself in a few malignant cases. But do 
not be deterred, by these hopeless views of treatment, from making 
early incisions, for cases occur where carbuncles on the face run the 
usual course after commencing with high fever. French surgeons 
have attained some good results by early burning out the malignant 
pustule. 

2. ACUTE INFLAMMATIONS OF THE MUCOUS MEMBEANES. 

While traumatic inflammation of the mucous membranes presents 
nothing peculiar, " acute catarrh " or " acute catarrhal inflammation " 
of these membranes is a peculiar form of disease which is anatomically 
characterized by great hyperaemia, cedematous swelling and free secre- 
tion of a fluid at first serous and subsequently muco-purulent, and is most 
frequently caused by catching cold or by infection. " Blennorrhea n 
is an increase of catarrh to such a degree that quantities of pure pus 
are secreted. Catarrh and blennorrhea may become chronic. Simple 
observation of exposed mucous membranes affected with catarrh 
shows that it may be very severe and long continued, without the 
substance of the membrane suffering much ; the surface of the mem- 
brane is hyperaemic and swollen, somewhat thick and puffy ; in rare 
cases there are superficial loss of epithelium and small defects of sub- 
stance (catarrhal ulcers), but it is only in very rare cases that these 
cause more extensive destruction. This observation is supported by 
post-mortem examination and histological investigation. The opinion 
now is, that there is only a rapid throwing off of the epithelial cells 



288 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

which approach the surface as pus-cells, and that the connective-tis- 
sue layer of the mucous membrane takes no part in the process. Al- 
though many attempts have been made to find segregation of the 
cells in the deeper epithelial layers of mucous membranes affected with 
catarrh, they were unsuccessful till Hemak, Buhl, and Rindfleisch, 
discovered large mother-cells in the epithelial layers of such mem- 
branes. 

Fig. 62. 




Epithelial layer of a conjunctiva affected with catarrh (after Rindjleisch). Magnified 400 diam- 
eters. 

It was most natural to explain this observation by assuming that 
the mother-cells were formed by endogenous segregation of the pro- 
toplasm, and subsequently turned out their broods (as pus-cells). 
Since, in opposition to this view, it was repeatedly shown that, if 
this were the case, the mother-cells should always be found on catar- 
rhal mucous membranes, while they were found only at first and 
then in small numbers, of late, they have been explained quite dif- 
ferently. Steudener and Vollcmann first advanced the idea that the 
young cells do not form in the older ones, but that, under certain me- 
chanically favorable influences, the latter may enter from without, but 
have nothing to do with the origin of the catarrh. Although this 
view is very difficult to prove, after much consideration and weighing 
of known facts, I consider it as very probable. This is not the place 
to go into details on the matter, but, since it has been proved by the 
cinnabar method that the white blood-cells escape from the vessels of 
the inflamed mucous membrane, and not only wander between the 
epithelium, but are also found as pus-cells in the catarrhal secretion, 
I should think catarrhal pus had the same origin as other pus, viz. 
that it came directly from the blood. Besides catarrhal inflammation 
mucous membranes are also subject to croupous and diphtheritic in 
flammations. When, in inflammation of a mucous membrane, the prod 
ucts of inflammation (cells and transudation) appearing on the sur 



PHLEGMONOUS INFLAMMATION. 289 

face form fibrine, and thus become a membrane clinging to the surface, 
which after a time dissolves into mucus and pus, or is lifted up by 
pus which is produced behind it from the mucous membrane, we call 
it a " croupous inflammation ; " the mucous membrane and its epithe- 
lium meantime remain intact, the parts are perfectly restored. Dip/ir 
theria is exactly similar to the above process, but the fibrinous layer 
is not only attached more firmly to the tissue, but the serum per- 
meating the substance of the membrane coagulates ; the circulation is 
thus impaired so much that occasionally the affected part becomes en- 
tirely gangrenous. In diphtheria, the disintegration and gangrene 
are prominent symptoms ; they probably depend on very rapid devel- 
opment of germs of fungi and infusoria in the diphtheritic membrane. 
Whether these fungous germs are, as many suppose, the cause of 
diphtheria, at present remains doubtful. The general affection, the 
fever, may be very severe in extensive croupous inflammation (as in 
the fine bronchi and alveoli of the lungs, croupous pneumonia), but in 
diphtheria it is of a more septic character ; the latter disease is far 
the most malignant. The mucous membrane of the pharynx and 
trachea is often exposed to both forms of the disease. Catarrhal con- 
junctivitis, wm\;h is so very common, may become diphtheritic, but 
rarely becomes croupous. The mucous membrane of the intestinal 
canal is seldom the seat of these diseases, the same is true of the mu- 
cous membrane of the genitals, which are so often affected with con- 
tagious blennorrhcea (clap, gonorrhoea). 

8. ACUTE INFLAMMATION OF THE CELLULAE TISSUE. PHLEGMONOUS 

INFLAMMATION. 

This term is pleonastic, for 7] (pXeyfiovr) means inflammation, but 
practically it is so exclusively applied to inflammation of the cel- 
lular tissue tending to suppuration, that every surgeon know T s what 
it means ; another name for the same disease is pseudo-erysipe- 
las ; it is just as much used, but seems to me less distinctive. The 
causes of this inflammation are in many cases very obscure ; a severe 
cold can rarely be proved to be the cause; frequently these in- 
flammations might result from infection, even if the cutis be unin- 
jured, but this is only hypothesis ; we have already seen these pro- 
gressive acute inflammations as a complication in injuries, especially 
as a-result of local infection from mortifying shrec^ of tissue in con- 
tusions and contused wounds. Spontaneous inflammation of the cel- 
lular tissue is most frequent in the extremities, more frequent above 
than below the fasciae, especially prone to affect the fingers and hand ; 
here it is called panaritium (corrupted from paronychia, inflammation 
around the nail, from ovvi- nail), and to distinguish it from deeper 
19 



290 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

inflammations also occurring in the fingers and hand, panaritium sub- 
cutaneum. If the inflammation affect the vicinity of the nail, or the 
nail-bed itself, it is termed panaritium sub ungue. Let us first con- 
sider the symptoms of phlegmon of the forearm : it begins with 
pain, swelling, and redness of the skin, and usually with high fever ; 
the skin of the arm is somewhat oedematous and very tense. With 
this commencement, which always announces an acute inflammation 
of the arm, its seat may vary greatly, and in the first day or two you 
may be unable to decide whether it is a case of inflammation of the 
subcutaneous cellular tissue, of perimuscular inflammation below the 
fascia, or even of periostitis or ostitis. The greater the oedema, the 
more considerable the pain, the less the redness of skin, and the less 
intense the fever, the more probably you have to anticipate a deep- 
seated inflammation which will terminate in suppuration. If the in- 
flammation attacks only the subcutaneous cellular tissue, and goes on 
to suppuration, as it does in most cases (though resolution is seen), 
this evinces itself in a few days by the skin becoming red at some 
point, and distinct fluctuation occurring. Then the pus either per- 
forates spontaneously, or is let out by an incision. If the inflamma- 
tion affect parts of the body where the skin, and especially the epi- 
dermis, is particularly thick, as in the hands and feet, there is at first 
little perceptible redness, as it would be hidden by the thick layer of 
epidermis. Pain, and a peculiar tension and throbbing in the inflamed 
part, announce the formation of pus under the skin. 

In some of these cases a portion of the skin becomes gangrenous, 
the circulation being disturbed by the tension of the tissue, part of 
the skin loses its vitality. The fasciae also are occasionally threat- 
ened by these inflammations ; in such cases they come through the 
openings of the cutis as large, white, consistent, thready tags. This 
is particularly the case in inflammations of the scalp, which not un- 
frequently extend over the entire skull ; the whole galea aponeurotica 
may thus be lost. 

Let us now pass to the more minute anatomical changes that take 
place in acute inflammation of the cellular tissue ; we shall not here 
return to the dispute as to whether vessels, tissues, or nerves, are first 
affected, but shall only speak of what we can find on direct anatomical 
examination. A series of observations on the cadaver, where in various 
cases we see inflammation in different stages, gives us sufficient infor- 
mation on this subject. The first things we find are distention of the 
capillaries and swelling of the tissue by serous exudation from the 
vessels, and a rich, plastic infiltration, varying with the stage, i. e., 
the connective tissue is filled with quantities of young, round cells. 
This, then, is the anatomical condition of the cellular tissue under the 



PHLEGMONOUS INFLAMMATION. 291 

oedematous, reddened, painful skin; subsequently the collection of 
cells in the inflamed connective tissue and fat becomes more promi- 
nent. These tissues become tense, and there is stagnation of blood 
in the vessels at various points, especially in the capillaries and veins ; 
at some places the circulation ceases entirely. This stagnation of the 
blood, which at first causes a dark-blue color, and then whiteness from 
the rapid discoloration of the red blood-cells, may extend so far as to 
cause extensive gangrene of the tissue, a result which we have already 
mentioned. But in most cases this does not occur, but while the cells 
increase, the fibrillar intercellular substance disappears, partly by the 
death of small tags and particles, partly by gradually becoming gelat- 
inous, and finally changing to fluid pus. 

Fig. 63. 




Tissue from a prepuce infiltrated from inflammation. The filamentary fibrillar formation of the tissue 
has entirely disappeared, from the softening influence of the cellular inflammation. The walls of 
the vessels are relaxed and perforated. Magnified about 500. 

As the inflammation progresses the entire inflamed part is finally 
changed to pus, that is, to fluid tissue, consisting of cells with some 
serous intercellular fluid which is mixed with shreds of dead tissue. 
If the process goes on in the subcutaneous cellular tissue, extending 
in all directions (most rapidly where the tissue is most vascular and 
richest in cells), the purulent destruction of tissue or suppuration 
will extend to the cutis from within, perforate it at some point, and 
through this perforation the pus will escape outwardly; when this 
occurs, the process often ceases to extend. The tissue surrounding 
the purulent collection is filled with cells and very vascular ; anatomi- 
cally it closely resembles a granulating surface (without any distinct 
granulations) lining the whole cavity. When the pus is all evacuated 



292 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

the walls come together and usually unite quickly. The plastic infil- 
tration continues for a time, causing the skin to remain firmer and 
more rigid than usual. But, by disintegration and reabsorption of the 
infiltrating cells, and transformation of the connectiYe-tissue substance, 
this state also returns to the normal. 

You will readily perceive that, anatomically, the process is much 
the same whether it be diffuse or circumscribed ; the finer changes of 
tissue in uie two are just the same. But in practice we distinguish 
between purulent infiltration and abscess. The first expression ex- 
plains itself: by an abscess we usually understand a circumscribed 
collection of pus, excluding further progress of the inflammation ; 
those forming rapidly, from acute inflammation, are called acute or 
hot abscesses, in contradistinction to cold abscesses, or those due to 
chronic inflammation. The following figure (Fig. 64) may render the 
formation of abscess more clear to you. 

You here see how the young cells gradually collect at the points 
where the connective-tissue corpuscles lay, while intermediate sub- 
stance constantly decreases, and how in the middle of the drawing, in 
the centre of the inflamed spot, the groups of cells unite and form a 
collection of pus ; every abscess at first consists of such separate col- 
lections of pus ; it grows by peripheral extension of the suppuration. 
Formerly, it was not doubted that, wherever pus-cells thus appeared 

Fig. 64. 




Diagram of purulent infiltration of the cutis connective tissue, forming an abscess in the 
middle. Magnified 350 diameters. 



in groups, they were to be regarded as a production of connective- 
tissue cells ; according to our present views, there is no doubt that 
these young cells are escaped white blood-cells, and are simply grouped 



PHLEGMONOUS INFLAMMATION. 293 

together from mechanical causes. The fat, which is usually plentiful 
in the subcutaneous cellular tissue, is generally destroyed in acute 

Fig. 65. 




Purulent infiltration of the cellular membrane. Magnified 350 diameters ; from a preparation 

hardened in alcohol. 

inflammation, the fat-cells being compressed by the new cell-masses, 
and the fat becoming fluid ; subsequently, it is occasionally found in 
the shape of oil-drops mixed with the pus. In this preparation you 
may see the microscopic appearance in inflammation of the cellular 
membrane. 

In examining such preparations we not unfrequently find filaments 
of coagulated fibrine infiltrated in the tissue ; possibly it is formed at 
the commencement of the inflammation, as previously described ; but 
it is also possible that these filaments appertain only to the fully- 
formed pus — possibly they are produced by the alcohol. 

I must call your attention to the fact that, until the process is 
arrested, we always have a progressive softening of the tissue, or sup- 
puration, in which it differs from a developed granulating surface, 
which only forms pus on its surface. All suppurative parenchymatous 
inflammations have a destructive or deleterious action on the tissue. 

As regards the relation of the blood-vessels to the new formation 
of the young tissue and its speedy disintegration, it has already been 
stated that they are at first dilated, and then the blood stagnates in 
them ; if the circulation be entirely arrested in certain portions of 
tissue, in which case the coagulation in the veins occasionally extends 
a considerable distance, the walls o£ the vessels and the clot suppu- 
rate, or fall into shreds, as far as the border where the circulation 



294 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

Flo. 66. 




Vessels (artificially injected) of the walls of an abscess that had been induced in the tongue of 
a dog. Magnified 25 diameters. 

begins again. As we have already seen when studying the detach- 
ment of necrosed shreds of tissue, vascular loops must form on this 
border of the living tissue ; that is, the whole inner surface of an 
abscess, in the arrangements of its vessels, is analogous to a granula- 
ting surface folded up sac-like. 

In regard to the lymphatic vessels, we may conclude from analogy 
that here, as in the vicinity of wounds, they are closed by the inflam- 
matory neoplasia; special investigations on this subject would be 
very desirable. So soon and so long as an abscess is surrounded by 
a vigorous layer of tissue infiltrated with plastic matter, for reasons 
already mentioned there will be no reabsorption of purulent or putrid 
substances from the cavity of the abscess. I can give you practical 
evidence of this, if in the clinic you will smell pus from an abscess 
near the rectum or in the mouth ; this pus has an exceedingly pene- 
trating, putrid odor, still is not reabsorbed by the walls of the veins, 
or is so to only a very slight extent ; symptoms of general sepsis very 
rarely occur. But at the commencement of inflammation, and later, 
when it is accompanied by rapid destruction of tissue, as well as in 
some progressive inflammations around contused wounds, and in 
phlegmonous inflammation of the cellular tissue, etc., if the lymphatic 
vessels are not yet stopped by cell-formation, organized inflammatory 
new formation does not occur, or comes on late as the gangrenous 



PHLEGMONOUS INFLAMMATION. 295 

destruction is being bounded; then the decomposing tissue enters 
the open lymphatics and acts as a ferment in the blood, causing fever. 

Although inflammation of the cellular tissue (cellulitis) may occur 
at any part of the body, it is most frequent in the hand, forearm, knee, 
foot, and leg. It is often accompanied, and, when extending, preceded, 
by lymphangitis, of which we shall speak among the accidental trau- 
matic diseases. 

The intensity and duration of the fever, accompanying these in- 
flammations, depend on the quantity and quality of the material re- 
absorbed. At first a quantity of these matters is thrown into the 
blood at once, hence at the onset there is usually high fever, some- 
times chill; as the inflammation progresses, the fever continues; it 
ceases when further absorption of the inflammatory product is arrest- 
ed by the above changes of tissue, when the process stops and the 
abscess is formed. The quality of the inflammatory material formed 
in cellular inflammation certainly varies greatly ; for instance, in some 
cases deep in the neck in old people there is such intense poisoning 
that the patients die without other symptoms. It is here the same 
as in carbuncle — some cases cause little fever, others produce fatal 
septic fever. If a phlegmon be due to a dangerous poison, such as that 
of glanders, we do not wonder at the fatal termination; but for the 
spontaneous cases it often seems very strange why some should be so 
very severe, while most of them are relatively mild. 

The prognosis of phlegmonous inflammations varies immensely 
with the location, extent, and cause. While the disease, occurring as 
a metastasis in a general phlogistic or suppurative diathesis, or in 
glanders, gives little hopes of cure, while deeply-seated abscesses in 
the walls of the abdomen or in the pelvis are very slow in their course 
and may prove dangerous from the locality, or, by destruction of fas- 
ciae, tendons, and skin, may impair the functions, most cases of phleg- 
mon on the fingers, hand, forearm, etc., are only moderate diseases of 
short duration, although very painful. The sooner suppuration occurs 
and the more circumscribed the inflammation, the better the prognosis. 

As regards the treatment, at the commencement of the disease its 
aim is to arrest the development of the disease if possible, that is, to 
attain the earliest possible reabsorption of the serous and plastic in- 
filtration. For this purpose there are various remedies : first, the ex- 
ternal use of mercury ; the inflamed part may be smeared with mer- 
curial ointment, the patient placed in bed, and the inflamed extremity 
enveloped in warm, moist cloths or large cataplasms. Ice also may 
be employed at first, if the whole inflamed part can be covered with 
several bladders of ice. Compression by adhesive plaster and band- 
ages is also a very effective remedy for aiding absorption, but it is 



296 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

little used in these inflammations, partly because of the pain it causes 
in such cases, partly because the remedy is not free from danger, as 
gangrene may be easily induced by a little too much pressure. If the 
process be not moderated soon after the employment of the above 
remedies, but all the symptoms increase, we must give up the hope of 
resolution, and resort to remedies to hasten the suppuration which we 
cannot avert; the chief of these is the application of moist warmth, 
especially in the shape of cataplasms. Then, as soon as fluctuation is 
detected at any point, we do not usually leave the perforation to Na- 
ture, but divide the skin to give vent to the matter; if the suppuration 
extends under the skin, we make several openings, at least I prefer 
this to one very large incision, from the elbow to the hand for instance, 
because in the latter the skin gapes widely, and takes a long time to 
heal. If the pus escapes naturally from the openings, great cleanliness 
is the only thing necessary; this is greatly assisted by local warm 
baths. 14 

While it is a very simple thing to open subcutaneous abscesses, 
" oncotomy " of deep abscesses requires great attention to the anato- 
my of the locality : for instance, the diagnosis may be very difficult in 
suppurations deep in the neck, in the pelvis, in the abdominal wall, 
etc., and can only be certainly made after a long period of observation; 
still, partly for the relief of the patient, partly to avoid a spontaneous 
opening into the abdomen, perhaps it may be desirable to evacuate 
the pus early. In such cases we must not plunge a bistoury boldly 
in, but dissect up layer after layer, till we reach the fluctuating cover- 
ing of the abscess ; then introduce a probe carefully, and dilate the 
opening by extending the blades of forceps introduced into it, so as to 
avoid haemorrhage from the deeper parts. Occasionally decompo- 
sition of the pus in an abscess causes so much gas as to give rise 
to a tympanitic percussion-sound; after being opened, these putrid 
abscesses should be syringed out and dressed with chlorine- water. 

4. ACUTE INFLAMMATION OF THE MUSCLES. 

Idiopathic acute inflammation of muscular substance is rela- 
tively rare. It occurs in the muscles of the tongue, in the psoas, 
pectoral, and gluteal muscles, and in those of the thigh and calf 
of the leg ; the usual termination is in abscess, although resolution 
has been observed. Metastatic muscular abscesses are very frequent 
in glanders. Regarding the special histological conditions, the in- 
terstitial connective tissue of the muscles, the perimysium is here, 
as in traumatic myositis, the chief seat of the purulent infiltration; 
from the very acute disease, the nuclei of the muscular filaments 



INFLAMMATION OF THE SHEATHS OF TENDONS. 297 

are destroyed, with the contractile substance and the sarcolemma; 
only on the stumps of the muscular filaments in the capsule of 
the abscess do we find the muscular nuclei (muscular corpuscles) 
in groups and adherent to the cicatrix ; in such cases, according to O. 
Weber, there is a considerable new formation of young muscle-cells. 
The symptoms of an abscess in the muscle are the same as those of 
any deep abscess ; their periods of development and perforation vary 
with their size and extent. In many cases there is contraction of the 
muscles in whose substance the abscess develops, as in psoitis. I shall 
not discuss whether this is the physiological result of the inflammatory 
irritation, or whether it is half voluntary, and made instinctively by 
the patient, but am rather inclined to the latter view, for in small 
and not very painful abscesses and in traumatic inflammations of the 
muscles, there is usually no contraction, but this occurs only in large ab- 
scesses, which are compressed by strong fascia?. 15 Abscesses in muscles 
should be opened as soon as fluctuation is felt, and the diagnosis 
certain. 

A very peculiar form of disease of the muscles, which, according to 
my view, should be classed among subcutaneous inflammations, has 
been recently discovered and described by Zenker; it occurs chiefly in 
typhoid fever, in the adductor muscles of the thigh ; in it the contrac- 
tile substance in the sarcolemma crumbles and is gradually absorbed, 
while new muscular filaments form to replace the old. Thus, in most 
cases, the parts are fully restored ; in other cases permanent atrophy 
of the muscle remains. There is no accurate knowledge as to whether 
this disease may lead to suppuration, although abscesses of the ab- 
dominal muscles have been observed after typhus. 

5. ACUTE INFLAMMATION OF THE SHEATHS OF TENDONS AND SUB- 
CUTANEOUS MUCOUS BUES^E (SEEOUS MEMBEANES). 

As is well known, the sheaths of tendons form shut sacs, which 
enclose some of the tendons of the hands and feet. They may be- 
come acutely inflamed from contusion, and in some few cases also 
spontaneously. Like all acutely-inflamed serous membranes, these 
sacs at first exude a quantity of fibrinous serum; recent fibrinous 
pseudo-membranes composed of wandering cells may again dissolve, 
but they may also induce temporary or permanent adhesions of the 
sheath to the tendon ; lastly, there is not unfrequently suppura- 
tion of the membrane, and at this time the tendon may become 
necrosed. Pain on motion and slight swelling are the first signs 
of such inflammation ; occasionally there is friction-sound, a grating 
in the sheath of the tendon, which may be perceived by the hand, 
or, still better, by the ear. This noise is due to the surfaces of 
the tendon and of its sheath having become rough from deposits of 



298 ACUTE NON-TRAUMATIC INFLAMMATION OF SOFT PARTS. 

fibrine and rubbing against each other, when the tendons are moved ; 
this form of subcutaneous inflammation is most common on the back 
of the hand, and almost always terminates in resolution. The very 
acute inflammations of the sheaths of the tendons, arising from un- 
known causes and going on to suppuration, are rare ; they begin like 
an acute phlegmon ; the subcutaneous cellular tissue quickly partici- 
pates in the inflammation ; the limb swells greatly, and the adjacent 
finger or wrist-joint may be drawn into the inflammation. Like the 
synovial membrane of the joints, that of the tendinous sheaths occa- 
sionally seems to furnish products that intensely affect the surround- 
ing parts. If, under suitable treatment, the disease does not go on to 
suppuration, or, if this be only partial, resolution slowly occurs ; the 
limb remains stiff a long while; the adhesions between the tendon 
and its sheath do not break down till after months of use. If there be 
extensive suppuration of the sheaths of the tendon (which, in the hand, 
has been termed "panaritium tendinosum"), the tendons usually be- 
come necrosed, and after a time may be drawn out of the abscess 
openings as white threads and shreds ; the membrane then degener- 
ates to spongy granulations. If the process be now arrested, one or 
more fingers will be stiff, and remain so for life. If the joints be also 
attacked in the fingers, there may be recovery with anchylosis ; but, if 
the wrist or ankle-joint be affected, its existence will be greatly endan- 
gered. In acute suppurative inflammation of the tendinous sheaths, 
the fever is occasionally slight at first, but in severe cases the disease 
may begin with a chill. The further the inflammation and suppuration 
extend, the less the process tends to formation of an abscess, the more 
continued the fever becomes, and it assumes a distinctly remittent 
form ; at the same time the patients are rapidly pulled down ; in a few 
weeks the strongest men emaciate to skeletons. The prognosis is 
bad when the fever runs on with intermittent attacks and chills. 

The treatment of subcutaneous, crepitating inflammations of the 
sheaths of the tendons consists in keeping the part quiet on a splint, 
and painting it with tincture of iodine ; if this does not afford speedy 
relief, a blister may be applied ; under this treatment I have always 
seen this form of inflammation disappear in a few days. If the symp- 
toms are severe from the first, quiet of the part is the first requisite ; 
this should be seconded by mercurial ointment and bladders of ice. 
This treatment should be persistently pursued ; in these cases I de- 
cidedly prefer it to cataplasms and local warm baths, which are very 
common. If absceses form, incisions and plenty of counter-openings 
should be made ; in these cases drainage-tubes are very useful, because 
the granulations projecting from the openings often obstruct the 
escape of the pus. If the suppuration will not stop, if the spongy 



INFLAMMATIONS OF SUBCUTANEOUS MUCOUS BUES.E. 299 

swelling of the limb continues, if crepitation appears in the joint be- 
tween the bones of the wrist (showing that the cartilaginous coverings 
have suppurated), and if the patient continues to sink, there is little 
hope of a termination in anchylosis of the hand, but the danger to 
life is so great that amputation of the forearm should be made ; the 
patient may thus escape with his life, and will soon recover his 
strength. 

Acute inflammations of the subcutaneous mucous bursce are less 
dangerous ; the bursa praepatellaris and anconea are most frequently 
affected either from injury or spontaneously ; they are connected 
neither with the joint nor with the sheaths of the tendons ; they be- 
come painful, fill with fibrinous serum, the skin reddens, and the cel- 
lular tissue in the vicinity participates in the inflammation ; but sup- 
puration rarely occurs if the patient is treated early. The remedies 
are mercurial ointment or tincture of iodine, keeping the limb quiet, 
and compressing the swollen bursa by applying wet bandages. 
Puncture is unnecessary, and may be injurious, from being followed by 
suppuration and a tedious suppurating fistula. 



CHAPTER XL 

ACUTE INFLAMMATIONS OF THE BONES, PERI- 
OSTEUM, AND JOINTS. 



LECTURE XXII. 

Anatomy. — Acute Periostitis and Osteomyelitis of the Long Bones : Symptoms, Ter- 
minations in Eesolution, Suppuration, Necrosis, Prognosis, Treatment. — Acute 
Ostitis in Spongy Bones. — Acute Inflammations of the Joints. — Hydrops Acutus ; 
Symptoms, Treatment.— Acute Suppurative Inflammations of Joints : Symptoms, 
Course, Treatment, Anatomy. — Acute Articular Bheumatism. — Arthritis. — Metas-. 
tatic Inflammations of Joints (Gonorrhoeal, Pyemic, Puerperal). 

The periosteum and the bones are physiologically so intimately 
connected that disease of one generally affects the other ; although, 
in spite of this, we are, for practical reasons, obliged to consider acute 
and chronic inflammation of the periosteum and of bone separately, 
still we shall often have to refer to their connection. I must here make 
a few preliminary anatomical remarks, as they are important for the 
comprehension of the following process : When speaking briefly of 
the periosteum, we usually mean, simply, the white, glistening, thin 
membrane, poor in vessels, which immediately surrounds the bone. I 
must here remark that this represents only a part of the periosteum 
that is pathologically of little relative importance. Upon this just- 
described inner layer of the periosteum lies, at points where no ten- 
dons or ligaments are inserted, a layer of loose cellular tissue, which 
is also to be considered as periosteum, and in which principally lie the 
vessels that enter the bone. This outer layer of periosteum is the 
most frequent seat of primary inflammations, either acute or chronic ; 
the loose cellular tissue of which this layer consists is very rich in 
cells and vessels, hence more inclined to inflammation than is the ten- 
dinous portion, poor in cells and vessels, which lies immediately on 
the bone. As to nutrient vessels, especially in the long bones, the 
epiphyses have their own supply, which, as long as the epiphyseal car- 



ACUTE PERIOSTITIS. 301 

triages continue, do not communicate with the vessels of the diaphysis, 
which have their own nutrient arteries. This distribution of the ves- 
sels explains why diseases of the diaphyses in young persons rarely 
pass to the epiphyses and the reverse. Genetically the articular cap- 
sule is a continuation of the periosteum, and a certain connection is 
often observed between articular and periosteal diseases, the diseases 
of one readily passing to the other. In the course of the following 
observations we shall have occasion to recur to these anatomical con- 
ditions. 

First, let us speak of acute periostitis and osteomyelitis, of which 
you have already heard something in the remarks on suppuration 
of bone in the chapter on open fractures (p. 221). This disease 
is not very frequent ; it occurs chiefly in young persons, and in its 
typical forms almost exclusively in the long bones. The femur is 
most frequently attacked, next the tibia, more rarely the humerus and 
bones of the forearm. I have seen the disease occur primarily or 
secondarily in the vicinity of acutely-inflamed joints, after catching 
cold, and after severe concussions and contusions of the bones. It is 
possible that the extravasation into the medulla from crushing or con- 
tusion of a bone may be reabsorbed, without the occurrence of any 
symptom but a continued pain as the result of the injury ; but such 
injuries may occasionally induce chronic affections of various sorts. 

In many cases we cannot discover whether only the periosteum or 
the medulla of the bone is affected ; the distinction is usually only ren- 
dered certain by the subsequent course and by the termination. The 
symptoms are as follows : The disease begins with high fever, not un- 
frequently with a chill ; there is severe pain in the affected limb, which 
swells at first without redness. The severe pain prevents motion of 
the limb; every touch or the slightest jarring is very painful; the 
skin is tense, usually cedematous, and occasionally the distended sub- 
cutaneous veins show through, a sign that the flow of blood to the 
deeper parts is obstructed. The inflammation may affect the whole 
or only part of a bone. But these symptoms simply indicate the ex- 
istence of an intense deeply-seated acute inflammation. But as idio- 
pathic inflammation of the perimuscular and peritendinous cellular 
tissue is very unfrequent, and rarely begins with so much pain, we 
shall not err in most cases if, with the above symptoms, we diagnosti- 
cate acute periostitis, perhaps accompanied by osteomyelitis. If, while 
there are great pain and fever, or complete inability to move the limb 
on account of pain, swelling does not occur for several days, we may 
suspect that the primary seat of the inflammation is the medullary 
cavity of the bone, and that at first the periosteum participates but 
little. In this stage the diseased part is in about the following con- 



302 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC. 

dition : The vessels of the medulla and periosteum are greatly dilated 
and distended with blood ; perhaps there may be stasis of blood at 
different points. The medulla, instead of its usual bright-yellow 
color, is dark blue, and permeated with extravasations ; the perios- 
teum is greatly infiltrated, and on microscopical examination of it you 
find numbers of young cells, as you also do in the medulla ; that is, 
there is plastic infiltration. In this stage, a complete return to the 
normal state is possible, and, if proper treatment is begun early, this 
is not so rare, particularly in the more subacute cases. The fever 
falls, the swelling decreases, and the pain ceases ; a fortnight after the 
commencement of the disease the patient may be recovered. Even 
when the process is somewhat further advanced, it may stop ; then a 
part of the new formation on the surface of the bone ossifies, and thus, 
for a time at least, there is thickening of the affected bone, which may 
again be absorbed in the course of months. 

In most cases the course of periostitis is not so favorable, but the 
process goes on, and terminates in suppuration, the symptoms being 
as follows : The skin of the swollen, tense, and painful limb is at first 
reddish, then brownish red ; the oedema extends further and further ; 
the neighboring joints become painful, and swell ; the fever remains 
at the same point; the chills are not infrequently repeated. The 
patient is much exhausted, as he eats little, and at night is kept 
awake by the pain. Toward the twelfth or fourteenth day of the dis- 
ease, rarely earlier, but often later, we may clearly distinguish fluctu- 
ation, and may then greatly alleviate the sufferings of the patient by 
letting out the pus through one or more openings, if the skin over the 
abscess is sufficiently thinned; for the opening of deep, stiff- walled 
abscesses which do not collapse may prove dangerous from decompo- 
sition of blood and pus in the insufficiently-encapsulated abscess. 
The spontaneous perforation, especially the suppuration of the fascias, 
occasionally takes a good while, and, moreover, the openings thus 
formed are usually too small ; they must subsequently be enlarged. 
If you introduce the finger through one of these artificial openings, 
you come directly on the bone, and in many cases find it denuded of 
periosteum. The extent to which this denudation occurs depends on 
the extent of the periostitis. It may extend the whole length of the 
diaphysis, and in these worst cases the symptoms are the most severe. 
Probably, however, only a half or a third of the periosteum is dis- 
eased, nor is the entire circumference of the bone necessarily affected, 
but perhaps only the anterior, lateral, or posterior portion is so. The 
periostitis is particularly apt to stop at the points of origin or inser- 
tion of strong muscles. In those cases of slight extent all the symp- 
toms will be milder. 



ACUTE PERIOSTITIS. 303 

Even in this stage the disease may take one of two different direc- 
tions : possibly, after the evacuation of the pus, the soft parts iaay 
quickly become adherent to the bone, as the walls of an acute abscess 
do to each other. I have seen this a few times in periostitis of the 
femur in children two or three years old. After the opening, a slight 
quantity of pus continued to discharge for only a short time. The 
openings soon closed entirely, the tumor receded, and perfect recovery 
took place. But, according to my experience, such a termination only 
occurs in small children. More frequently, as a result of the suppu- 
ration of the periosteum, the bone is mostly robbed of its nutrient 
vessels, and partly or wholly dies, leaving the condition termed 
necrosis, or gangrene of the bone. The extent of this necrosis will 
essentially depend on the extent of the periostitis. The partially or 
entirely destroyed diaphysis of the long bones must be detached as a 
foreign body, as we have seen to be the case in gangrene of the soft 
parts and traumatic necrosis. This requires a long time ; hence the 
process of necrosis, the detachment of the portion of dead bone or 
sequestrum, and every thing connected with it, is always a chronic 
one. We shall have to speak of this hereafter. Before the inflamma- 
tion passes into this chronic state, acute suppuration continues for a 
time after the first opening of the abscess. Various complications, 
even pyaemia, may occur. Whenever these patients are feverish, they 
are in danger. 

We must again return to the medulla of the bone, which we left 
in the first stage of inflammation. Here, also, the inflammation may 
terminate in suppuration. If the osteomyelitis be diffuse or total, the 
whole medulla may suppurate. This suppuration may even assume a 
putrid character, and induce septicaemia. If there be extensive sup- 
purative osteomyelitis, with suppurative periostitis, death of the dia- 
physis of the bone is certain. Should there be only partial suppura- 
tion of the medulla, or if there be none at all, the circulation of blood 
in the bone may be preserved and the bone remain viable. It may 
not infrequently occur that, under such circumstances, the bone will 
waver for a time between life and death, as the feeble circulation 
nourishes the bone very incompletely. Acute suppurative osteomye- 
litis, without participation of the periosteum, probably does not occur ; 
it is not infrequently combined with osteophlebitis, which may end in 
putrefaction or suppuration of the thrombus, and is prone to induce 
metastatic abscesses. Another not infrequent, though not constant, 
accompaniment of osteomyelitis is suppuration of the epiphyseal car- 
tilages in persons in whom they still exist, that is, till about the 
twenty-fourth year. The process is not difficult to explain. The sup- 
puration may extend to the epiphyseal cartilage partly from the 



304 ACUTE INFLAMMATIONS OF THE RONES, PERIOSTEUM, ETC. 

medulla of the bone, partly from the periosteum. If it suppurate, 
the continuity of the bone is destroyed, and at the seat of the epi- 
physis there is motion, as in fracture ; dislocations may also be caused 
by contraction of the muscles. Usually there is only one such epi- 
physeal separation of the affected bone, above or below ; in rare cases 
it is double. I have once seen this double separation of the epiphy- 
ses in the tibia ; several times I have seen separation of the lower 
epiphysis of the femur, once of the upper end of this bone, once of 
the lower end of the humerus, twice of the upper end. In one case 
I saw epiphyseal softening, with luxation of the lower end of the 
femur, occur without suppuration. It has already been stated that 
inflammation of the neighboring joints are apt to accompany perios- 
titis. These articular inflammations usually have a rather subacute 
course. The serous fluid collecting in the joint is usually reabsorbed 
as the acute disease of the bone subsides, but the joint often remains 
swollen, and not infrequently permanently stiff. Several times, also, 
I have seen acute periostitis and osteomyelitis of the femur succeed 
acute articular rheumatism of the knee. Lastly, we must also men- 
tion that this osteomyelitis may occur in several bones at once. 

The diagnosis as to how far periosteum and bone are affected in 
the acute disease cannot be made with any certainty, but can only be 
decided by the extent of the consequent necrosis ; and even this is no 
accurate measure, for the periostitis may end in suppuration, while 
the inflammation in the bone may end in resolution, or only cause 
some interstitial formation of bone. The process may start : 1. In 
the loose cellular-tissue layer of the periosteum; this suppurates. 
If the suppuration be limited to this layer, after opening the abscess 
we may pass the finger directly to the surface of the bone, which we 
find covered with the granulating tendinous part of the periosteum ; 
if the latter layer also suppurates, as it not infrequently does, the 
bone lies exposed, and the suppuration may continue into it. Thus 
osteomyelitis accompanies periostitis. If it be denied that the loose 
cellular layer is periosteum, but is to be regarded as part of the inter- 
muscular cellular tissue (which would not be natural, because the 
vessels escaping from the bone lie chiefly in this layer), then there is 
no such thing as acute periostitis ; for the tendinous portion of the 
periosteum is as little liable to primary inflammation as the fascias and 
tendons. 2. The inflammation begins in the bone, and thence extends 
to the periosteum and cellular tissue ; osteomyelitis is the primary, 
periostitis the secondary, disease. Then there is pus not only in the 
bone, but on its surface, close under the tendinous portion of the 
periosteum. This is elevated by the pus, as far as its elasticity per- 
mits ; it is then perforated, and the pus escapes into the cellular tissue 



ACUTE PERIOSTITIS. 305 

Here it causes more suppuration, and thus the process advances to 
the surface. Hoser asserts that in these cases fluid fat is pressed, by 
the strong arterial pressure, from the cavity of the bone through the 
Haversian canals of the cortical substance to the surface of the bone, 
so that we may diagnose osteomyelitis from pus mixed with fat-drops 
rising from under the periosteum. Moreover, in a few cases, Hoser 
found a remarkable elongation of the bone, and a relaxation of the 
neighboring joints, after osteomyelitis. He refers this to too rapid 
growth of the articular ligaments and epiphyseal cartilages. 

In the prognosis of acute periostitis and osteomyelitis we have to 
distinguish between the danger to the existence of the bone and to 
life. If the disease induces partial or total necrosis of the bone, the 
disease may be very protracted ; it may last several months, or even 
years. Acute periostitis and osteomyelitis, especially in the femur, 
and still more when double, is always dangerous to life, because pyae- 
mia is so apt to occur, and in children, because of the profuse suppu- 
ration, it is the more dangerous the longer the condition remains 
acute and the further it spreads. 

In treating this disease we may accomplish more if we are called 
early ; one of the most efficient remedies is painting the whole limb 
with strong tincture of iodine. This remedy should be continued till 
large vesicles form. Of course the patient is to be kept recumbent, 
which in most cases does not need to be urged, as the pain keeps him 
quiet. Since commencing this treatment I am so well satisfied with 
it, that I have almost given up the other antiphlogistics ; cups, leeches, 
mercurial ointment, etc. When the vesicles formed by the iodine 
dry up, you apply more. Derivation to the intestinal canal by saline 
purgatives aids the treatment, as it does in all acute inflammations. 
Some surgeons greatly praise the local application of ice at the com- 
mencement of the disease. Should suppuration nevertheless occur, 
and distinct fluctuation be felt at the thinnest part of the skin, we 
may make several openings in such a way that the pus shall escape 
without being pressed out ; then the swelling usually subsides quick- 
ly ; it is most favorable when the fever ceases early and the disease 
becomes chronic. If the fever continues, the suppuration remains 
profuse, the pains do not cease. We may try to relieve this condi- 
tion by continued applications of bladders of ice, with which we also 
try to alleviate any inflammations of the joint that may occur. I have 
also derived great advantage from the application of a fenestrated 
plaster-splint, which should be supported with hoops on account of 
the large openings that must be made in it ; in cases where there is 
detachment of the epiphysis, it is absolutely necessary that the limb 
should be fixed, if only to render the daily dressing less painful 
20 



306 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC. 

Many surgeons do not follow this treatment, which is backed by a 
series of favorable cases. Some recommend making large, deep in- 
cisions down to the bone at the very start, or at least as soon as 
suppuration begins. Such extensive wounds are bad in feverish pa- 
tients ; I am satisfied that, under these circumstances, this heroic treat- 
ment renders the condition worse, it increases the predisposition to 
pyaemia. The idea that in acute osteomyelitis exarticulation should 
be made at once, as otherwise pyaemia is unavoidable, seems to me 
even more erroneous. This belief is certainly untrue, and under 
such circumstances amputation is not indicated, first, because at the 
onset the diagnosis of osteomyelitis is not absolutely certain, as the 
case might possibly be one of simple acute periostitis ; secondly, be- 
cause the prognosis in exarticulation of large limbs, if done for acute 
disease of the bone, is always very doubtful. In acute periostitis and 
osteomyelitis, of the tibia for instance, I should only amputate at the 
thigh if the suppuration were very excessive, and acute suppuration 
of the knee-joint should occur. Should the disease affect the femur 
and run an unfavorable course, I should scarcely hope to save the pa- 
tient by an operation so dangerous as amputation at the hip-joint. 
"We may accomplish much by great care of the patients, who are gen- 
erally youthful. A young girl with osteomyelitis and periostitis of 
the tibia had sixteen chills in twelve days, and nevertheless recovered, 
although part of the tibia became necrosed, and the foot was anchy- 
losed. 

I will here add a few remarks about suppurative periostitis of the 
third phalanx of the finger, which is, perhaps, the place where it most 
frequently occurs. As this inflammation in the hand and fingers is 
usually called panaritium, this periostitis of the last phalanx is termed 
panaritium periostale. This, like any periostitis, is very painful; 
it is a long while — sometimes eight or ten days — before the pus per- 
forates outward. The termination in partial or total necrosis of the 
phalanx is common, and cannot be prevented even by an early in- 
cision, although we often have to make one to relieve the disagree- 
able, throbbing, burning pain, partly by the loss of blood, partly by 
splitting the periosteum. As the termination in suppuration can 
scarcely ever be avoided, we try to induce it by cataplasms, hand- 
baths, etc., and thus hasten the course. 

Thus far we have only spoken of acute inflammation of the peri- 
osteum, and medulla of the long bones, but have not considered that 
of the spongy bones. Nor have we considered the question of in- 
flammation of the bone-substance proper. Is there such a thing ? I 
think this must be answered in the negative, for I consider that dila- 



ACUTE PERIOSTITIS. 30 7 

tation of the vessels, cell-infiltration, and serous imbibition of the tis- 
sue, in their various combinations, constitute the essence of acute in 
flammations. In the compact bone-substance (as in the cortical layer 
of a long bone) all these requirements cannot occur. In many places 
at least, the capillary vessels are so closely embedded in the Haver- 
sian canals that they cannot dilate much ; a certain amount of serous 
infiltration of the bone is imaginable ; but the firm bone-substance 
cannot possess much capability of swelling. If the term inflamma- 
tion be made so general as to include every quantitative and qualita- 
tive disturbance of nutrition, it would be a very peculiar view, in 
which I do not participate. Every tissue attacked by inflammation 
changes its physical and chemical nature, and in acute inflammation 
of the soft parts this takes place rapidly; the connective tissue es- 
pecially is quickly changed to a gelatinous, albuminous substance ; the 
tissue of the cornea and cartilage may also change very quickly. For 
chemical reasons this is impossible in bone ; time is required for the 
chalky salts of the bone to dissolve, and the bone-cartilage left deli- 
quesces like other tissue. Hence, inflammation of compact bony tis- 
sue, severe though it be, cannot run its course very rapidly ; it always 
takes a long while. The above refers only to compact bone-substance ; 
spongy bones may readily become inflamed, that is, there may be in- 
flammation of the medulla contained in the spongy bones which has 
the same peculiarities as that of the long bones, only it is not collected 
together as it is in them, but it is distributed in the meshes of 
the bones ; each space contains many capillaries, connective tissue, 
fat-cells, and nerves ; acute inflammation of the spongy bones first oc- 
curs in these interspaces, and gradually extends to the bone proper. 
What is called acute ostitis of a spongy bone is at first only acute os- 
teomyelitis. This when idiopathic is rarely acute, but is usually 
chronic, sometimes subacute. On the other hand, there is a traumatic 
acute osteomyelitis of spongy bones, about which we shall here say 
something, although we have discussed its more important features 
when treating of suppuration of bone. Imagine an amputation 
wound close below the knee : the tibia has been sawed through its 
upper spongy part ; traumatic inflammation occurs in the medulla of 
the bone, in the meshes of the bone-substance, with proliferation oi 
vessels, cell-infiltration, etc. ; this leads to development of granula- 
tions, which grow out from the medulla and soon form a granulating 
surface ; this cicatrizes in the usual manner. But subsequently, if 
you have a chance to examine such a stump, you find that, at the sawed 
surface of the bone, the meshes are filled with bone-substance, and 
the outer layer of the spongy bone is transformed to compact bony 
substance ; that is, the cicatrix in the bone has ossified. This is the 



308 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC, 

normal termination not only of traumatic but of spontaneous ostitis : 
the bony cicatrix ossifies. There may also be suppuration, putrefac- 
tion of the medulla of spongy bones, as in long bones ; osteophlebitis 
and its consequences may also occur. In the lecture on suppuration 
of bone (p. 216) and healing of open fractures we treated fully of the 
changes which occur after the bone has lost its periosteum, of the 
development of granulations on the surface of compact bone-sub- 
stance, and of the accompanying superficial necrosis. 

Here I will merely add that we sometimes meet multiple inflam- 
mations of the bones as we do multiple acute inflammations of the 
soft parts (acute polyarticular rheumatism) ; these may occur simul- 
taneously in the two corresponding bones of the lower extremities, 
or may follow each other; e. g., osteomyelitis of the tibia, suppura- 
tive inflammation of the knee-joint, osteomyelitis of the femur, puru- 
lent inflammation of the hip-joint ; in one case there was also osteo- 
myelitis of the other femur and purulent coxitis of the other side. 
Even such cases may possibly terminate favorably, but this is very 
rare; they usually end fatally. 16 



We now come to acute inflammations of the joints. As we have 
previously spoken of traumatic articular inflammations, you already 
know some of the peculiarities of diseased joints. You also know 
that serous membranes have a great tendency to excrete fluid exu- 
dation when irritated, but that this exudation may also contain pus, 
if the inflammatory irritation be very intense. As there is a pleurisy 
with effusion of sero-fibrinous fluid (the ordinary form), and a variety 
with purulent effusion (so-called empyema), so in joints we speak of 
serous synovitis, or hydrops, and of purulent synovitis, or empyema ; 
both forms of the disease may be either acute or chronic, and they in- 
duce various diseases of the cartilage, bone, articular capsule, perios- 
teum, and surrounding muscles. You will see that it is always more 
complicated with these diseases the more complicated the affected 
part is. Of late, great importance has been attached (especially by 
French surgeons) to speaking, first, of diseases of the synovial mem- 
brane, then of those of the cartilage, articular capsule, and bone, cor- 
responding to the anatomical conditions. Correct as this division 
would be, if it were only a question of representing the pathological 
anatomical changes, it is of little use in practice. The surgeon al- 
ways views inflammation of the joint as a whole, and, although he 
should know which part of the joint suffers most, this is only a part 
of what he should know ; course, symptoms, and constitutional state, 
equally demand his attention, and determine the treatment. Hence 
the entire clinical appearance will determine the divisions of this, 
of many other diseases. 



INFLAMMATION OF THE JOINTS. 309 

At present we are speaking only of apparently spontaneous acute 
inflammations of the joints. In many cases they are evidently due to 
catching cold, in other cases .their causes are obscure. Some of the more 
subacute cases are of metastatic nature and appear as pyaemia. But 
at present we shall speak only of the idiopathic inflammations, which, 
in contradistinction to the traumatic, are termed rheumatic, as they are 
often due to cold. Patients requiring your aid for such acute inflam- 
mations of the joints, will present somewhat different symptoms. If, 
for illustration, we again take the knee-joint, you will have about the 
following picture : A strong, otherwise healthy man has taken to bed? 
because for a day or two his knee has been swollen, hot, and painful ; 
you find this on examining the knee, you also find distinct fluctuation 
in the joint, and that the patella is somewhat lifted up, and always 
rises again if pressed down ; the skin over the joint is not red ; the 
patient lies with his leg stretched out in bed, has no fever, and, if you 
ask him, can bend and extend the knee, though with some difficulty. 
You here have an acute serous synovitis, or hydrops genu acutus. The 
anatomical condition of the knee is as follows : the synovial membrane 
is slightly swollen and moderately vascular ; the articular cavity full 
of serum, which has mingled with the synovia ; there are a few flocculi 
of fibrine in the fluid, the rest of the joint is healthy. Anatomically 
the state is just like a subacute bursitis tendinum or a moderate 
pleurisy. This disease is generally cured without difficulty ; quiet, re- 
peatedly painting with tincture of iodine, or a few blisters, or com- 
pression with wet bandages, suffice to remove the affection in a few 
days, or at least to take off its acuteness ; all the symptoms of the 
acute inflammation may subside, the patient may go about with 
scarcely any difficulty, but there remains too much fluid in the joint, 
a hydrops chronicus of the joint is left. 

You may be called to another patient with inflammation of the 
knee-joint. A few days previously the young man has caught cold ; 
soon after this his knee has begun to pain, high fever has come on, 
perhaps a heavy chill ; the joint has constantly grown more painful. 
The patient lies in bed, with the knee flexed so that the thigh is 
strongly rotated outward and abducted ; he resists every attempt tc 
move the leg, as it causes him terrible pain. The knee-joint is greatly 
swollen and feels hot, but there is no fluctuation, the skin is cedematous 
and red about the knee, the whole leg also is cedematous ; on account 
of the pain it is impossible to extend the knee or to flex it more. 
What a contrast to the former case ! If you have a chance to examine 
the joint in this stage, you find great swelling of the synovial mem- 
brane ; it is very red, puffy, and microscopically appears infiltrated 
with plastic matter and serum. In the joint there is usually a little 



310 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC. 

flocculent pus mixed with the synovia, there may also be pure pus. 
The surface of the cartilage looks cloudy, and microscopically perhaps 
shows little change beyond turbidity of the hyaline substance ; possi- 
bly the cartilage cavities are somewhat enlarged and filled with an un- 
usual number of cells. The tissue of the articular capsule is cedematous. 
Here you have a purulent very acute synovitis, in which the cartilage 
threatens to participate ; should the disease continue, and the pus in 
the joint increase, you may correctly call it empyema of the joint. 

The difference between the first and second forms of acute syno- 
vitis is essentially that, in the second, the tissue of the synovial 
membrane is deeply affected, while in the first the increased secretion 
is the chief feature. Between these two forms are subacute cases, in 
which the secretion becomes purulent and collects in great quantity, 
without there being any great destruction of the synovial membrane. 
R. Volkmann calls this " catarrhal inflammation " of the joint ; it is 
somewhat more painful than ordinary acute hydrops, from which the 
catarrhal purulent form may proceed, though this is rarely the case. 
I have already said what was necessary about the course and treat- 
ment of acute hydrops. The course and results of the more paren- 
chymatous synovitis, which is predisposed to suppuration, depend 
greatly on when the treatment is begun and what it is. Usually a 
few leeches are applied and then the joint is poulticed, from an idea 
of the old school, that rheumatic articular inflammations should be 
treated with warm applications. I consider leeches almost useless in 
these affections ; perhaps there may be a question about keeping the 
limb warm, for this is often pleasant to the patient ; it alleviates the 
pain in inflammations of the serous membranes, often more so than cold 
does ; at least the latter must act for some time before having a favor- 
able effect. I explain this as follows : The warm applications induce 
fluxion to the vessels of the skin, and thus empty those of the syno- 
vial membrane ; but this effect is not long continued ; fluxion to the 
inflamed deeper parts returns again, and is stronger than to the artifi- 
cially-warmed skin. On application of a large bladder of ice to the 
joint, the vessels of the skin contract, and perhaps drive the blood to 
the vessels of the inflamed part more strongly than before, till gradu- 
ally the cold has its effect on these also, and if the cold continues the 
effect becomes permanent. It seems more rational always to use cold 
in these cases ; in very acute inflammations of the joint the employ- 
ment of ice-bladders has also proved very practical. Besides using 
cold, you may also induce active derivation to the skin by strong tinc- 
ture of iodine, or by a large blister. But besides these remedies it is 
most important io bring the joint into a proper position and keep it 
there, for, if we do not obtain a perfect cure, and the joint remains 



INFLAMMATION OF THE JOINTS. 311 

stiff, the flexed position of the knee, which is so frequent, is a very un- 
fortunate addition to the stiffness, as it renders the limb nearly if not 
entirely useless. Why the acutely-diseased joint, especially in intense 
suppurative synovitis, almost always involuntarily assumes a flexed 
position, is a difficult question, which may be answered in various 
ways: it has been said that there is a sort of reflex action on the 
motor muscular nerve from the irritation of the sensory nerves of the 
synovial membrane, and that this is the cause of the muscular con- 
traction. Bonnet^ a French surgeon, who has done much for the 
treatment of diseases of the joints, thinks that in great distention of 
the joint with pus, or even by swelling of the synovial membrane, the 
flexed position may be caused mechanically, as the space in the joint 
is greater in the flexed than in the extended position ; he has tried to 
prove this by injecting the joints in the cadaver, and by filling them 
completely he has brought them into the flexed position. Against 
this it may be said that in hydrops acutus, where there is usually more 
fluid in the joint than there is in purulent synovitis, the flexion does 
not occur, and also that in acute inflammations, where I could satisfy 
myself of the non-existence of fluid, there was flexion. It seems to 
me that the acute, puffy, painful swelling of the synovial membrane 
is the chief cause of the flexion, hence I should incline to the first ex- 
planation, according to which the pain is the irritation that induces 
contraction of the muscles of the limb : other muscles also, in parts 
suffering from acute pain, contract, as the cervical muscles in deep- 
seated abscesses of the neck. The malposition should be relieved ; 
this should be done for each joint in such a way that in case of com- 
plete stiffness its position shall be most favorable. The hip and knee- 
joint should be extended, the foot and elbow at right angles ; the 
wrist and shoulder do not get out of position ; the former usually re- 
mains extended, the latter usually takes such a position that the arm 
lies against the thorax. There is very great difference in the frequency 
of acute disease in the different joints ; the knee is most frequently 
affected, then the elbow and wrist ; acute inflammation of the hip, 
shoulder, and ankle, is rare. Acute articular inflammations are more 
frequent in young persons than in old, but hardly ever occur in chil- 
dren. But, to return again to the improvement of the position of the 
joint : you will tell me this is impossible. Chloroform is here useful ; 
this remedy has become most important in the treatment of inflamma- 
tions of the joints. You narcotize the patient deeply, and can then 
move the limb without trouble ; the muscles, which previously con- 
tracted on the least touch, now yield without difficulty. If we continue 
with our former hypothetical case, you extend the knee, envelop it in 
a thick layer of wadding, and apply a plaster-splint from the foot to 



312 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC. 

the middle of the thigh. When the patient awakes, he will at first 
complain of severe pain ; give him quarter of a grain of morphia and 
apply one or two bladders of ice over the plaster-splint to the knee ; 
the cold acts slowly, but finally proves effective, and in twenty-four 
hours the patient feels tolerably comfortable. The slight compression 
made by the well padded plaster-splint also has a favorable antiphlo- 
gistic action ; if there be fever, you may give cooling medicines and 
saline purgatives ; but the patient needs no further treatment. Be- 
fore applying the dressing, you may have the limb rubbed with mer- 
curial ointment or painted with tincture of iodine. It is best to apply 
the dressing even in the most acute stage ; of course it must be done 
very carefully, avoiding any strangulating pressure. Recently it has 
been shown that, even in very acute inflammations of the joints, sur- 
prising results may be obtained by extension with weights. It is 
very interesting to observe how a continued moderate traction lessens 
the pain in the joint and relaxes the muscles. But much depends on 
the application of the dressings, and I cannot too strongly urge on 
you to attend carefully to these apparently simple mechanical things, 
whose importance you will not correctly estimate till thrown on your 
own resources in practice, and obliged to attend to the minutest de- 
tails yourself. 

If called to the case early, you may sometimes not only arrest the 
acute stage of the disease, but may preserve to your patient a mov- 
able joint. But, even if called late, the above treatment should be 
pursued. If the pain is relieved and the fever ceases, you may re- 
move the dressing in a few weeks, for the disease lasts several weeks 
under any circumstances ; perhaps three to five months may elapse 
before the inflammation entirely disappears; gradually the normal 
condition and the former mobility return, then the patient should be 
earnestly warned against taking cold or excessive motion, for a second 
attack might not turn out so well. 

Supposing the acute process does not subside under the treatment 
instituted, but continues to progress, it may pass into a chronic form, 
or remain acute ; we shall hereafter treat of the former case. Let us 
at present suppose that the pain, instead of subsiding, becomes more 
severe, and you are obliged to split the dressing along the front ; you 
find the knee more swollen, distinctly fluctuating, and the patella 
very movable, while the patient has high fever. If the disease con- 
tinues, the fluctuation may extend farther and farther, upward to the 
thigh, for instance, and the subcutaneous cellular tissue of the thigh 
and leg may participate in the suppuration. Formerly this extension 
was attributed to subcutaneous bursting, or partial suppuration of the 
synovial sacs around the joint, especially of the large one under the 



INFLAMMATION OF THE JOINTS. 313 

tendon of the quadriceps femoris, and of the bursa poplitea ; to pre- 
vent this misfortune it was considered advisable to tap the joint with 
a trocar, in the above stage of the disease, to let out most of the pus, 
and then carefully close the opening. From my own experience I should 
consider this operation as rarely indicated, for I have convinced my- 
self, by careful examinations of patients, and occasionally of the 
cadaver, that these periarticular abscesses in the cellular tissue, oc- 
curring in acute synovitis, and also in ostitis of the articular extremi- 
ties, form separately, and break into the joint late, if they do so at 
all. With the development of these abscesses the general condition 
of the patient is usually impaired ; he has high fever, with intercur- 
rent chills, his cheeks fall in, he emaciates, loses his appetite, and 
becomes sleepless. Quinine and opium finally lose their effect, and, 
unless you amputate the thigh early enough, the patient dies from the 
exhausting suppuration and continued fever; perhaps, also, he may 
have metastatic abscesses. If, by the applications of ice, by one or 
more incisions for evacuating the pus, by quinine and opium, you suc- 
ceed in breaking the acute stage of the disease, and making it chronic, 
you will not obtain a movable joint, but even if it is flexed at a right 
angle, the leg will be useful ; this is the best result that we can gain 
after days and weeks of anxiety and care, if the inflammation reaches 
the above grade. The anatomical changes in a knee-joint in this 
stage of inflammation are as follows : The joint is filled with thick 
yellow pus, mixed with fibrinous flocculi ; the synovial membrane is 
covered with dense purulent fibrous rinds, under which it is very red 
and pufiy, partly ulcerated ; the cartilage is partly broken down into 
pulp, partly necrosed and peels off; the bone under it is very red or 
infiltrated (osteomyelitis ; usually in these cases a secondary, rarely a 
primary disease). 

The prognosis of this disease is not very bad in young, vigorous 
persons, when the proper treatment is resorted to early ; it is very 
bad, almost absolutely fatal, in old, decrepit persons. 



In the above I have pictured to you typical cases of the two forms 
of synovitis, the serous and parenchymatous (purulent), and am satis- 
fied that in practice you will readily recognize these pictures again ; 
and you will have no difficulty in applying what has been said of the 
knee to other joints. Now I must add that there is still another 
acute or subacute form of articular inflammation, which offers some 
peculiarities. I refer to acute articular rheumatism. This very pe- 
culiar disease, which will be treated of more fully in the lectures on 



314 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC. 

mternal medicine, is characterized by its attacking several joints at 
once, and its tendency to cause inflammations of other serous mem- 
branes, such as the pericardium and endocardium, the pleura, and 
rarely the peritonaeum and arachnoid. This simultaneous disease of 
these membranes and of the joints marks the affection as one impli- 
cating the whole body from the start ; indeed, from the importance 
of the organ affected, the pericarditis and endocarditis are often so 
prominent, and so much influence the treatment, that the surgical 
treatment of the joints is a very secondary matter ; this is the more 
apt to be the case, as this disease, although very painful, rarely proves 
dangerous to the limb or to life. The chief symptoms of the local 
affection, beyond which the disease rarely proceeds, are, great pain in 
the joint on every motion or touch, oedema of the surrounding soft 
parts, and rarely redness of the skin. From the few autopsies that 
have been made, it appears that the synovia increases somewhat, is 
sometimes mixed with flocculi of pus, and the synovial membrane is 
swollen and red ; the cartilage is seldom implicated ; the collection 
of fluid is not often so great as to cause fluctuation. Acute rheuma- 
tism is very frequent, but it is rarely fatal, so that the pathological 
anatomical appearances are little known. From all the symptoms of 
this disease, it is evidently a specific, limited disease, of a peculiar 
character, but with a course so atypical, and causes so obscure, that 
its actual character has not yet been determined. I have my doubts 
whether, besides this polyarticular^ we can speak of a monarticular 
acute, rheumatism^ for it is just the multiplicity of the points of 
inflammation, and their slight tendency to suppurate, that charac- 
terize the disease ; at all events, I should not consider an inflammation 
limited to one joint as a symptom of acute rheumatism, unless pleu- 
risy, pericarditis, or some other complication peculiar to rheumatism, 
also occurred ; should none of these come on, the disease is purely local, 
a simple inflammation of the joint, which is probably called rheumatic 
simply because it is supposed to be due to catching cold. In acute 
rheumatism, the resolution of the articular inflammation and the res- 
toration of the joint to its functions are so common that we rarely see 
any other termination. That the disease is tedious, and generally 
lasts six or eight weeks, is not so much due to the duration of the 
affection in a single joint as to its attacking first one joint, then an- 
other, aod exacerbations readily occurring in joints that had recov- 
ered ; thus the disease proves tedious, both for physician and patient, 
and the greatest watchfulness and care are necessary to avoid all 
sources of injury that may again arouse the disease. It is exceedingly 
rare for one of the affected joints to go on to intense suppuration or 
empyema ; more frequently, in spite of the subsidence of the disease, 



INFLAMMATION OF THE JOINTS. 315 

a joint remains stiff and painful, and passes into a state of chronic 
inflammation. You see that the prognosis of this disease, as far as it 
concerns the joint, may be called very favorable ; without any inter- 
ference from the physician, the joint-inflammations generally run a 
favorable course. Hence all that we do for the local disease is to en- 
velop the joint in wadding, tow, oakum, or wool, to protect it from 
changes of temperature. Mild cutaneous irritants and painting with 
tincture of iodine may also be useful. For alleviating the pain in the 
joints and hastening the course of the disease, Stromeyer and others 
recommend the employment of bladders of ice, and generally keeping 
the joint cool, rather than warm. But I think this treatment will find 
few disciples, for it is quite troublesome, and experience shows that 
the articular inflammations get on well without such applications. 
Internally, we may give diuretics, diaphoretics, or cooling salts ; in 
heart-affections, local antiphlogistics, digitalis, etc., are indicated, as 
will be taught you more particularly in special pathologies, and in the 
medical clinics. 

Next to acute rheumatism comes acute arthritic inflammation of 
the joints. The attack of podagra or chiragra is also specific and 
belongs to true gout ; here, also, the articular inflammation is an acute 
serous synovitis, but with very little secretion of fluid in the joint. 
But one thing peculiar to acute arthritic inflammation is the never- 
failing coincident inflammation of the surrounding parts : the peri- 
osteum, sheaths of the tendons, but especially of the skin; this 
always reddens, becomes glistening and tense, as in erysipelas, and is 
very painful ; it even desquamates occasionally after the attack. 
Acute arthritic articular inflammation is far more painful than rheu- 
matic. We shall hereafter speak of the treatment of arthritis and the 
arthritic diathesis. 



There is still another variety of acute articular inflammation, the 
metastatic, about which we shall have something more to say when 
treating of pyaemia. Acute or subacute metastatic inflammation of 
the joint is usually at first serous, but soon purely suppurative syno- 
vitis. Several forms may be distinguished : 

1. Gonorrhoea! inflammation of the joints. This occurs in men 
suffering from gonorrhoea ; occasionally, also, it occurs after the intro- 
duction of bougies into the urethra ; it attacks the knee-joint almost 
exclusively. Some authors assert that it is especially apt to develop 
when the gonorrhoea is arrested suddenly. This is not my own ex- 
perience. In proportion to the frequency of gonorrhoea, it is very 
rare, but I have seen it quite frequently when a patient with active 



316 ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, ETC. 

gonorrhoea has caught cold. The incomprehensible connection be- 
tween purulent catarrh of the urethra and inflammations of the knee- 
joint might be denied, and the simultaneous occurrence of the two 
diseases be considered as accidental ; but the experience of too many 
surgeons, and also cases where inflammations of the knee-joint occur 
after other irritations of the urethra (as by bougies), speak in its 
favor. Gonorrhceal gonarthritis usually attacks both sides, and is a 
subacute serous synovitis, which generally soon disappears under 
proper rest, avoidance of new irritation of the urethra, blisters, tinc- 
ture of iodine, and slight compression of the joint ; and, after reab- 
sorption of the fluid, it ends in perfect cure. But irritability of the 
joint is apt to remain, and not unfrequently the same person getting 
another gonorrhoea is again attacked with inflammation of the joints. 
In some cases chronic articular rheumatism is said to follow gonor- 
rhceal gonarthritis. 

2. PycBmic inflammation also occurs very frequently in one knee, 
as well as in the ankle, shoulder, elbow, and wrist ; rarely in the hip. 
It is a pure purulent synovitis, subsequently accompanied by suppu- 
ration of the periarticular cellular tissue, but usually with subacute 
course, and hence we do not always find it fully developed at the time 
of autopsy. Pysemic patients do not always die with suppuration of 
the joint, and I have witnessed reabsorption in cases where the patient 
lived through the purulent infection. The treatment does not differ 
from that above given ; if the collection of pus is excessive, puncture 
will relieve the pain. Suppurations of the joint due to injuries, and 
lacerations of the urethra by careless catheterization, and usually 
accompanied by chills, are of course pyaemic, not gonorrhoeal. In 
Berlin I treated a young man who had a rupture of the urethra caused 
by bougies, and consequently an abscess of the left shoulder, with 
suppuration of the acromial joint of the clavicle, which induced sub- 
luxation of that bone. The patient recovered perfectly; and, as 
the abscess was not large, it was not opened. A year later I saw 
the young man again. The abscess had become somewhat smaller, 
fluctuation was still distinct; but, as it caused no disturbance of 
function or other difficulty, and the patient was blooming and 
healthy, I avoided opening the abscess, and advise you to do the 
same with cold abscesses which evidently communicate with a joint, 
as the opening does little good and may do much harm, by pos- 
sibly inducing acute inflammation of the joint and very disagree- 
able results. 

3. Puerperal inflammations of the joints. Puerperal fever is a 
torm of pyaemia that may occur after parturition. Hence, the suppu- 
rative inflammations of the joints occurring at that time come under 



INFLAMMATION OF THE JOINTS. 317 

the above category of pyaamic, suppurative synovitis. But not unfre- 
quently, the third or fourth week after parturition, there is an acute 
suppurative inflammation of the knee and elbow joints, which has been 
referred to various causes. Some say it is a simple form of acute 
articular inflammation due to catching cold, to which women are par- 
ticularly liable after confinement, because they perspire so much. 
Others are of the opinion that these late inflammations of the joints 
are also symptoms of pyaemia that have been overlooked and are 
isolated, and hence consider them as metastatic. Let this be as it 
may, it is at all events certain that these cases have nothing specific. 
They run either an acute or subacute course, and, under suitable treat- 
ment, may be so controlled that the joint will remain movable ; but 
sometimes a more chronic course begins later and terminates in 
anchylosis. The prognosis is not very bad. They rarely reach the 
highest grade of acuteness. The treatment is the same as that 
already given for acute suppurative synovitis. 

I would also mention that purulent articular inflammations occur 
in the pyaemia of the newly-born ; children are even occasionally born 
with them, as has been witnessed by myself and others. Inflamma- 
tions of the joints may develop and even run their course during foetal 
life, as is shown by the cases where children are born with joints fully 
developed but anchylosed. 



APPENDIX TO CHAPTERS L-Xl 

RETROSPECT.— GENERAL REMARKS ON ACUTE 
INFLAMMA TION 

Gentlemen : Thus far I have given you a number of clinical sur- 
gical pictures representing various forms of acute inflammation. We 
have seen injuries and their results, as well as the acute surgical dis- 
eases occurring without injury, and have studied the disturbed physi- 
ological processes, the means of their removal, and the process of this 
removal. It seemed as if this method would be stimulating for you, 
and that it was permissible, as you were supposed to have some 
knowledge of general pathology and some starting-point for patho- 
logical, physiological, and histological investigations. Still, it will 
not be superfluous, at the close of this first and most extensive sec- 
tion of our work, to give a brief rfoume of the present views of in- 
flammation, which have been greatly advanced by recent labors of 
Cohnheim, Samuel, Arnold, and others. 



318 GENERAL REMARKS ON ACUTE INFLAMMATION. 

I will begin by sajdng that from our ignorance of the parti cipa- 
tion of nerves in inflammation, we must leave them out of the ques- 
tion. Vessels, blood, and tissue form almost exclusively the objects 
of our study. 

Dilatation of the blood-vessels is an important factor in inflam- 
mation ; still, neither the hyperemia from hinderance to the current 
of blood in the veins (congestive hyperemia) or dilatation of the 
arteries from paralysis of their walls (as in the rabbit's ear after 
division of the cervical sympathetic), nor the sudden primary dilata- 
tion from mechanical and chemical irritations, necessarily leads to 
inflammation. About the latter form of vascular dilatation I have 
something to add to what has already been said. It is about the 
following symptom : You rub the eye, and it becomes red ; you rub 
the skin, and it becomes red, as it also does if you apply warm wa- 
ter ; you put snow on the skin, and it becomes white, then red. All 
of these reddenings soon pass off if their causes only acted a short 
time and were soon removed. The investigations mentioned in Lec- 
ture V. referred to the mode of origin of these hyperemias, but they 
are now considered unsatisfactory. The symptom itself is completely 
estimated by Cohnheim ; still, even under the action of heat, cold, 
and chemical influences, if w T e suppose a direct momentary paralysis 
of the vascular walls, from what we have thus far seen, it appears 
strange that a paralyzing influence should extend from a circum- 
scribed pressure or tear to an extensive portion of surrounding vas- 
cular territory, with a sort of wave-like motion. It seems to me we 
know no more about this "affluxus" to the "stimulus' 5 than we for- 
merly did. But it is important, as Cohnheim has shown that where 
inflammations occur after physical or chemical influences, these pri- 
mary fluxions may have passed over long before the new hyperemia 
which leads to and continues with the inflammation ; and the pri- 
mary fluxions may entirely fail, but a regular inflammation with its 
hyperemia nevertheless occurs. Hence the fluxion immediately fol- 
lowing the irritation is not an absolutely necessary factor of the 
inflammation. 

A rabbit's ear whose vessels have been paralyzed and dilated by 
section of the sympathetic does not inflame ; its tissue becomes more 
tense from oedema, but nothing more ; there is no further disturb- 
ance of nutrition in the vessels and tissues. 

Extensive congestion, however, is more serious. It has already 
been stated in Lecture Y. that slight increase of intravascular press- 
ure, such as occurs after moderate injuries, quickly passes over and 
has no effect on the inflammation. But if the congestion be very 
extensive and cannot be equalized, there is so copious an exudation 



CIRCULATION IN INFLAMED TISSUE. 319 

of serum in the tissue (oedema) that it cannot be carried off by the 
lymphatics ; sometimes there is free escape of red blood-corpuscles 
through the walls of the capillaries into the tissues (diapedesis). 
Cohnheim stated it as probable that the diapedesis resulted through 
openings in the capillary walls. Arnold not only confirmed this, 
but indicated the so-called stigmata (the small openings which be- 
come visible between the cells forming the capillaries, after staining 
with silver) as the point of escape, and also showed that blood -serum 
flowed out through these stigmata. If the hinderance to the circu- 
lation be of such a nature that blood can continue to flow, the only 
results will be oedema and diapedesis ; if the circulation be entirely 
arrested, gangrene results. 

Coming at last to hyperemia as it occurs in inflammation, it is 
neither the immediate result of temporary inflammation, nor of paral- 
ysis of the vaso-motor nerves, nor of obstruction to the circulation, 
but of a peculiar alteration of the walls of the vessels, especially of 
the capillaries and veins. What chemical or physical changes occur 
at the same time in the walls of the vessels cannot be stated ; but 
we conclude that the vessels in the inflamed part are permanently 
dilated, and permit the free escape of white blood-corpuscles (not 
only at the stigmata, but at any point in their walls), and that the 
substance of these vessels is softened and more yielding. Why this 
is so, certainly cannot be determined in all cases ; it is considered as 
a direct effect of the cause of the inflammation, though it does not 
occur for some hours. The inflamed borders and areolae around 
sharply-bordered cuts or stabs are just as difficult to explain as the 
primary fluxions. We must even involuntarily suppose that a dis- 
turbance can never be accurately confined to the part supplied by a 
certain vessel, but that it must spread somewhat, least so in cuts, 
stabs, or rapid burns, and most so after certain chemical actions. 
Still, this is no true explanation ; it is merely a limitation of obser- 
vation. 

Let us now consider the blood and its circulation in inflamed 
tissue. Primary fluxion is accompanied by greatly increased ac- 
tivity of the movement of the blood, especially in the arteries, 
which again becomes normal as the primary dilatation of the vessels 
recedes. In the vessels which dilate permanently, in the borders 
and areola of the inflammation, the rapidity of the circulation grad- 
ually diminishes, especially in the veins ; the blood may move by 
impulses, or occasionally stop completely. This stasis, which is not 
at once accompanied by coagulation of the blood, was formerly re- 
garded as a necessary part of true inflammation, and had many expla- 
nations, which hardly interest us now, as we know that many inflam- 



320 GENERAL REMARKS ON ACUTE INFLAMMATION. 

mations run their course without stasis, as well as that this stasis 
often disappears in spite of progressing inflammation. If it contin- 
ues, the blood finally coagulates in the vessel (thrombosis), the results 
of which vary with local conditions and the extent ; there may be a 
return to the normal state by collateral dilatation, or gangrene may 
result. The circulation in the inflamed part is at first slow and ir- 
regular, and again becomes normal. Meantime numerous white 
blood-cells collect along the walls of the small veins and capillaries ; 
then they wander through the walls of the vessels into the tissues, 
whose interstices become filled (cellular, or, if excessive, purulent 
infiltration) ; and finally they reach the surface (superficial suppura- 
tion, purulent catarrh). 

We have now the complete picture of acute inflammation ; but 
the process may recede at the time of dilatation of the vessels and 
arrest of the white blood-cells, and even subsequently, when cellular 
infiltration has advanced quite far, without leaving any change per- 
ceptible in the tissue that has been infiltrated or the vessels which 
have been dilated. But at a certain height of the purulent inGltra- 
tion the tissue disappears entirely, and is replaced by pus (an ab- 
scess forms), or by an interstitial neoplasia (granulation tissue), 
which, if it does not die, becomes connective tissue (cicatrix), with 
vessels and nerves. 

The question arises, What causes this atrophy of inflamed tissue ? 
Is it the direct effect of the cause of the inflammation or of the cellu- 
lar infiltration ? Here we come to the third important point in in- 
flammation, namely, the part taken by the tissue itself. If we first 
consider the inflammations caused by known chemical or physical 
causes, it is evident they cannot act on the vessels and blood with- 
out at the same time affecting the tissue. Samuel starts from the 
inflammation induced by chemical means, and explains it as a result- 
ant of the union of the cause of the inflammation with the tissue, 
the walls of the blood-vessels and the blood. The wandering of the 
blood-cells, their infiltration in the tissue, and the accompanying 
changes, he regards as secondary processes. If the action of concen- 
trated sulphuric acid on the tissue causes such a metamorphosis that 
circulation of blood and other fluids is no longer possible, the tissue 
is directly killed ; but the most essential thing in the inflammation 
is the change of tissue affected by dilute sulphuric acid (whether at 
the borders of a part cauterized by strong acid or where only dilute 
acid was used), where circulation still continues. According to this, 
if I have rightly understood SamueVs explanation, the disturbance 
in the inflamed tissue would vary in different cases, according as the 
active cause was an acid, an alkali, ethereal oil (as oil of turpen- 



DILATATION OF VEINS AND CAPILLARIES. 32 1 

tine), or an acrid oil (as croton-oil), etc. The condition of the in- 
flamed tissue would differ also with action of extreme cold, great 
heat, crushing, after steam on exposed surfaces or serous membranes, 
etc. So we should have to renounce entirely a uniform representation 
of the chemical processes in the inflamed tissue. I do not know if 
this view will ever prove popular in this form. Hitherto we have 
classed these changes of tissue at the seat of inflammation all to- 
gether ; just as by concussion of the brain we should mean not only 
the moment of concussion, but also its immediate effect on the brain 
and its functions. If the concussion be followed by inflammation of 
the brain, the changes caused by the concussion may influence the 
nature and extent of the inflammation; but we do not say that a 
brain suffering from concussion is already inflamed. The same is 
true of contusions : if the normal function of a tissue has been af- 
fected by a concussion, but its function not entirely destroyed, the 
circulation will differ from normal, and this modification we call in- 
flammation, but do not so term the immediate result of the contu- 
sion. The processes in the tissues, after chemical, physical, or me- 
chanical injuries, are essentially similar, differing only in extent and 
intensity ; they are what we term inflammation, and in it the tissue 
itself plays an important part, which varies with the way the cause 
has directly affected the tissue. 

A constant perceptible result of acute inflammation is dilatation 
of the veins and capillaries, with escape of white blood-cells and cer- 
tain disturbances of the physiological functions of the affected tissue. 
For all this to occur, one function of the vessels, especially that of 
the cellular elements of keeping the blood in the channels formed by 
them, must be disturbed ; but would such a disturbance be confined 
to the walls of the vessels, and not extend to the adjacent tissue ? 
This is not very probable. The granular cloudiness occurring in in- 
flamed muscle, the indistinctness of the filaments in inflamed con- 
nective tissue, the granular disintegration in inflamed nerve-filaments, 
the rapid loss of color of red blood-cells in acutely inflamed tissue, 
all indicate that certain constant changes go on in the tissue also, 
which usually lead to gradual solution or death of the tissues, unless 
gangrene occurs from rapid increase of the process. I acknowledge 
there is no proof that these changes begin simultaneously with those 
in the vessels, and that they may be regarded as an immediate re- 
sult of the latter ; for if we find these alterations of tissue without 
dilatation of the vessels and cell-emigration, or if we artificially cause 
this state by obstructing the circulation to the injured part {Samuel), 
there may be a doubt as to whether it is to be termed inflammation 
in the ordinary sense ( Cohnheim). But, on the other hand, at- 
21 



322 GENERAL EEMARKS ON ACUTE INFLAMMATION. 

tempts have been made to distinguish the changed condition of the 
vessels which permits the extensive escape of white blood-cells from 
inflammation. When studying chronic inflammation, we shall see 
that all of these factors can occur separately, and that it is only their 
combination which forms what we call inflammation. 

Virchow located the inflammatory disturbances chiefly in the 
tissue ; he was led to this partly by the microscopic changes just 
mentioned, partly from the observation that on irritation young 
cells appeared even in non-vascular tissues, like the cornea and car- 
tilage, just as .they do in vascular tissues. These latter observa- 
tions, which were made at a time when the emigration of white 
blood-cells was not understood, can now be differently interpreted 
(Lecture VI.). We doubt now just as little as formerly that carti- 
lage-cells and some others, as certain endothelia of serous membranes 
(JRindfleisch, Kundr at), young epithelial cells (JRemak, JBuhl, Rind- 
fleisch), etc., on being irritated in a certain way, will form new pro- 
toplasm and new cells in themselves, will divide up, and may thus 
lead to formation of new tissue. It is still doubtful whether all 
cells thus formed have independent movements, like pus-cells ; but 
very few observers now believe that developed connective tissue, 
corneal or bone corpuscles, acquire this peculiarity; it is pretty gen- 
erally recognized that formation of pus does not result from local 
proliferation of fixed connective-tissue cells, according to VircJiovfs 
theory. Many regard it as still undecided how much the wandering 
cells have to do with inflammatory new formations ; from my obser- 
vations I can hardly doubt that the tissue which causes healing by 
first intention, as well as granulation tissue, may proceed from wan- 
dering cells, although another mode is possible (by offshoots, direct 
outgrowth from the tissue, Lecture VI.). The transformation of 
wandering cells into connective tissue seems to me quite plausible, 
for, according to my investigations, they probably originated from 
connective-tissue cells, namely, from the stellate cells, filaments of 
lymphatic glands. Of late, attempts have been made to explain why 
the above-mentioned tissue-cells, such as cartilage-cells, after certain 
irritations, begin to enlarge, divide, and finally to produce new tis- 
sue, by the hypothesis that every protoplasm, supplied with proper 
nourishment, would grow and divide up if not hindered by the press- 
ure of the tissue in which it develops ; the partial escape of the nu- 
cleus, as from injury or increased distensibility of the tissue, the 
nutritive conditions being otherwise good, is said to be enough to 
start the remains of the cell into growth. This hypothesis, which 
was advanced by Thiersch for another object, and which has been 
warmly taken up and generalized by Samuel, seems very ingenious, 



FORMATION OF FIBRINE. 323 

and I think it may prove the fruitful basis of future observations. 
But tissue-development is dependent on other important factors be- 
sides the conditions of nutrition and pressure, as on inherited pecu- 
liarities of the protoplasm ; and the above hypothesis does not suit 
all cases — for instance, the endogenous cell-development of the endo- 
thelium after inflammatory irritation of the peritoneum. 

It is not known whether there is a primary disturbance of nutri- 
tion in the tissues themselves, independent of the blood-vessels and 
their functions, that induces the specific inflammatory alteration in 
the vessels. The deposit of urates in the tissue of certain parts of 
the body in arthritis is usually regarded as of this nature ; but the 
deposit requires participation of the vessels, and so they and the 
tissues are simultaneously affected. An experiment of Cohnheim 
shows that continued exclusion of blood from a blood-vessel may so 
affect its walls that when the blood again enters there will be a free 
emigration of white blood-cells. It was mentioned above that con- 
tinued stasis of the blood did not have this effect on the walls of the 
vessel where it was stagnated ; but from clinical grounds it is prob- 
able that the pressure of extensively and rapidly distended vessels 
on the parts around has something to do with their inflammation. 

It is very probable that inflammations may be induced not only 
by chemical, physical, and mechanical causes, which act from with- 
out directly on certain parts of the body, but also by primary disturb- 
ances of nutrition in the tissues and of the circulation, which develop 
in the body without perceptible cause. 

I must not forget to mention one symptom which formerly played • 
a great role in inflammation, but is now hardly mentioned ; that is, 
the formation of fibrine in some inflammations. This occurs chiefly, 
indeed almost exclusively, in inflammation of the connective tissue, 
and sometimes on the surface of serous sacs, of fresh and granulat- 
ing wounds, and of mucous membranes (of pharynx, larynx, and 
bronchi) ; in other cases the nutrient fluid in the connective tissue 
assumes a fibrinous rigidity. It has been already mentioned that 
the formation of fibrine is not from an excess of fibrine in the blood, 
but from chemical alteration in the inflamed parts. Fibrine forms 
in the inflamed tissue, but is not a constant result of inflammation. 
The great difference of the other symptoms occurring with fibrinous 
inflammations is remarkable. While rapid formation of a moderate 
amount of fibrine favors healing by the first intention and partial 
adhesion of the surfaces of serous membranes, when often scarcely a 
trace of inflammation or fever is perceptible, in other cases, from 
some enigmatical cause, a very moderate fibrinous deposit in the 
tissues (as fibrinous deposit on the mucous membrane of the throat, 



324 GENERAL REMARKS ON ACUTE INFLAMMATION. 

diphtheria) causes death. It is very evident that fibrinous harden- 
ing of the tissue fluids is one of the severest alterations of their nu- 
trition ; and, as experience shows, it often ends in necrosis. Still, 
the severe general symptoms and extensive inflammatory redness in 
these processes cannot be due simply to the formation of fibrine, but 
seem referable to absorption of the products of decomposition in the 
diseased tissue, which has a very rapid poisonous action. In the 
acute inflammations with formation of fibrine there seems to be a 
scale of malignancy similar to those without such formation, so that 
this would seem to be rather an accident due to the variety of the 
tissue and its locality ; and while its significance is very important, 
it is not essential to the inflammation, nor does it materially change 
the course. 

The serous transudation also, which accompanies acute inflam- 
mations, deserves a short notice. In many cases it certainly is the 
result of change of pressure in the vessels at the seat of inflamma- 
tion ; but it is just as much due to impaired function of the walls 
of the vessels and of the tissue ; it is often a prominent symptom in 
inflammations of the connective tissue, especially of serous mem- 
branes. The walls of the vessels cannot hold the serum of the 
blood ; the tissue does not prepare it ; veins and lymphatics do not 
carry it away, especially if they are covered and stopped up by 
fibrine (in inflammation of serous surfaces on which the lymphatics 
open). The serum in acutely inflamed tissue is essentially different 
from that which, without inflammation, causes dropsy, for it not 
only contains wandering cells and disintegrated red blood- cells, but 
also the soluble products of the inflammation. The removal of this 
fluid by the veins and lymphatics releases the tissues from a consid- 
erable pressure and carries off the injurious products, it is true ; but 
part of it at least is carried into the blood, and probably causes the 
inflammatory fever. This has already been fully treated of. 

Now we might speak of the causes why circumscribed and often 
purely mechanical irritations, acting on small portions of the body, 
occasionally excite such intense spreading inflammations, and of the 
way these spread. But I will not now trouble you further with this 
subject. I have already said something about it in Lecture XXI., 
and shall hereafter have occasion to say more. 

Pathological anatomists have paid too little attention to these 
questions ; surgeons see their importance too often, and seek in 
vain for a means to arrest these spreading inflammations. In the 
clinic there will be many opportunities to call your attention to 
these important points. 

It is in the nature of our times to undervalue the significance 



VALUE OF THEORETICAL REFLECTIONS. 325 

and practical value of these so-called theoretical reflections with 
which I have perhaps fatigued some of you. But hereafter, when 
you have been in practice for some years, you will hardly be able to 
read and understand a medical work if, during your student-life, you 
have not acquired a basis on which to build. After some years of 
practice some of you, who are now sated with lectures, will long 
to hear a continuous scientific exposition of important morbid pro- 
cesses. 



CHAPTER XII. 
GANGRENE 



LECTURE XXIII. 

Dry, Moist Gangrene.— Immediate Causes.— Process of Detachment. — Varieties of Gan- 
grene according to the Eemote Causes.— 1. Loss of Vitality of the Tissue from 
Mechanical or Chemical Causes. — 2. Complete Arrest of the Afflux and Efflux of 
Blood. — Incarceration. — Continued Pressure. — Decubitus. — Great Tension of the 
Tissue. — 3. Complete Arrest of the Supply of Arterial Blood. — Gangrena Spon- 
tanea.— Gangrena Senilis. — Ergotism. — L Noma.— Gangrene in Various Blood- 
Diseases. — Treatment. 

We have already spoken frequently of gangrene and mortification. 
You know in general what they mean, and have already encountered 
a series of cases where there was local death of a part ; but there are 
many other circumstances, with which you are not yet acquainted, 
which favor gangrene ; all of which we shall include in this chapter. 

You already know the word gangrene to be perfectly synonymous 
with mortification. Originally it was only used to express the stage 
where the dying part was still hot and painful ; that is, not completely 
dead. This was called " hot mortification," while the moist " cold 
mortification " was called by the old authors sphacelus. The word 
mummification is also employed for dry gangrene. From the moment 
the circulation ceases, moist gangrene is perfectly analogous to ordi- 
nary putrefaction. Although it cannot always be certainly stated why 
dry gangrene occurs in one case and moist in another, we say gener- 
ally that when the circulation ceases suddenly, especially if the parts 
have been previously inflamed or ©edematous, moist gangrene occurs. 
Dry gangrene — mummification or shrinking of the parts — is more fre- 
quently due to gradual death, where the circulation has continued 
jceebly in the deeper parts, and the serum has been carried off from 
the gradually-dying parts by the lymphatic vessels and veins. Rapid 
evaporation of the fluid also induces gradual dryness. It is certainly 



CAUSES OF GANGRENE. 327 

true that even in moist gangrene a superficial dryness of the skin may 
occasionally be obtained by removing the hard layer of the epidermis, 
which readily peels off from the decomposing limb ; we may also 
greatly favor the drying by applications of substances having a strong 
affinity for water, such as alcohol, solutions of corrosive sublimate, 
sulphuric acid, etc. ; but we cannot obtain so complete a mummifica- 
tion as sometimes occurs spontaneously. Hence, dry gangrene is not 
a simple putrefaction, but a rather complicated process, which gradu- 
ally leads to arrest of the circulation. 

The immediate cause of death of individual parts of the body is 
always the complete cessation of the supply of nutriment consequent 
on arrest of circulation in the capillaries ; under some circumstances 
the chief arteries or veins of an extremity may be locally obstructed, 
and, nevertheless, the blood finds its way by neighboring branches 
into their lower or upper parts. Hence, obstruction of an artery can 
only be the immediate cause of gangrene when collateral circulation 
is impossible. This may be due partly to anatomical conditions, partly 
to great rigidity of the walls of small arteries, partly to very exten- 
sive destruction of the walls of the artery, as when the femoral is 
obstructed from the bend of the leg to the foot, the nutrition only 
ceases when the capillary circulation is rendered impossible by these 
circumstances. But it is not always necessary that cessation of cir- 
culation in a small capillary district, or in the parts supplied by one 
small artery, should cause actual decomposition ; under such circum- 
stances the disturbance of nutrition may assume a milder form, espe- 
cially when this limited disturbance of circulation comes on slowly 
and gradually. In this case there is molecular disintegration of tissue, 
which shrinks and dries to a yellow cheesy mass, in short, there is a 
series of metamorphoses which in the cadaver appear as dry, yellow 
infarctions ; this is essentially merely a sort of dry gangrene limited 
to a small spot. If this disturbance of nutrition and molecular disin- 
tegration of tissue take place on a surface, we call it ulceration / the 
whole series of so-called atonic ulcers, to which we shall hereafter 
return, are mostly due to such quantitative disturbances of nutrition. 
Hence, intimate as is the connection between the causes of dry gan- 
grene and ulceration, still, the various forms of gangrene are well 
marked and peculiar, as you will see from what follows, as there is 
generally not only molecular disintegration of tissue, but death of 
whole shreds of tissue, or even of an entire limb. A priori^ it is cer- 
tainly supposable that complete closure of all the veins returning 
olood from a limb, should induce complete stasis in the capillaries ; 
but in practice this is very unlikely to occur, for the veins are so very 
numerous, and in almost all parts of the body there are two ways for 



328 GANGRENE. 

the return of blood, viz., the deep and subcutaneous veins, which 
communicate freely ; if one way be closed, the other will be at least 
partly open. When dry gangrene occurs in the skin and deeper soft 
parts, they usually assume a grayish-black, then a coal-black hue. In 
cases where the parts were previously inflamed, the skin appears at 
first dark violet, then whitish yellow, it only becomes brownish or 
grayish black in case of partial drying ; dead tendons and fascia? 
change their, color little. When, from disturbance of the circulation, a 
considerable portion of tissue ceases to be nourished, the border be- 
tween dead and living regularly becomes more distinctly marked ; 
around the dead skin there forms a bright-red line, the so-called line 
of demarcation. This redness is caused by distention of the capillary 
vessels, which is partly due to collateral circulation in them, partly to 
fluxion induced by the decomposing fluids, and exactly resembles the 
redness around the edges of a wound with loss of substance, especially 
of a contused wound, as we have already explained. Along with these 
changes in the vessels there is an active cell-infiltration in the line 
of demarcation, by which the tissue, whatever its nature may be, is 
partly softened and dissolved. All over the borders of the living 
tissue young cells in the form of pus appear in place of the firm tissue, 
and then the coherence of the parts ceases. The dead becomes de- 
tached from the living, and on the borders of the latter there is a layer 
of tissue changed by infiltration of plastic matter and ectasia of the 
vessels, granulations. To express this simply in surgical language we 
say : The dead tissue must be thrown off from the living by free sup- 
puration, and this detachment of the dead tissue is followed by active 
granulations which cicatrize in the usual manner. This process repeats 
itself in all tissues, in all forms of gangrene, sometimes quicker, some- 
times more slowly, in exactly the same way, even in bones, as you 
know from the necrosis of the ends of the bone in open fractures. But 
we shall not here treat of gangrene of bones, as it is so intimately 
connected with their other chronic diseases that we shall have to speak 
of it when treating of them. The time required for the detachment 
of the dead tissue may vary greatly. It depends : 1. On the size of 
the dead portion ; 2. On the vascularity and consistence of the tissue ; 
3. On the strength and vitality of the patient. 

As gangrene is usually the result of other diseases, it is not always 
easy to correctly group the sj^mptoms which are to be referred to it. 
If the line of demarcation has formed, and the process of detachment 
is going on, an effect on the general health is apparent when the 
gangrene affects large extremities. Then there is a general marasmus, 
a gradual loss of strength, depression of the bodily temperature, small 
pulse, dry tongue, a half-soporose state in which the patient grows 



DECUBITUS. 329 

weaker and weaker, and finally dies, without our being able to dis- 
cover in the cadaver any particular cause of death, although in other 
cases putrid metastatic abscesses are found in the lungs. These cases 
are one form of chronic septicaemia ; I have no doubt that the repeated 
absorption of putrid matters, during the development of gangrene, by 
the blood and lymphatic circulation winch partly continues, may be the 
cause of death. I propose to return to this question in the next 
section. 

After these general remarks, we must study more carefully the 
different varieties of gangrene, according to their remote and proxi- 
mate causes, and their practical importance : 

1. Complete loss of vitality of the tissue through mechanical or 
chemical action, such as crushing, contusing, great heat or cold, caus- 
tic acids and alkalies, continued contact with ammoniacal urine, with 
carbunculous poison, poisons from certain serpents, putrid matters 
that act as ferments, etc., come under this head. We have already 
spoken of some of these varieties ; we shall shortly come to others of 
them. 

2. Complete arrest of the circulation, by circular compression or 
other mechanical cause, is in many cases the cause of capillary stasis 
and gangrene. For instance, if you surround a limb firmly with a 
bandage, you will have, first, venous congestion, then oedema, and 
finally, gangrene. • Let us take a practical example : if the prepuce 
be too small and be forcibly drawn back over the glans so as to 
cause a paraphimosis, the compressed glans, or in this case more 
frequently the compressing ring, becomes gangrenous. The mortifi- 
cation of strangulated hernia depends on the same cause. 

Continued pressure also, by arresting the afflux and efflux of blood, 
may lead to gangrene, especially in persons in whom the heart's action 
is weakened by long disease, or who by general septic intoxication 
are already disposed to gangrene. 

Decubitus, the so-called bed-sore, is such a gangrene caused by 
continued pressure, but all sorts of bed-sores are not gangrenous from 
the first, for in some cases they are rather to be compared to 
a gradual maceration of the epidermis and cutis, as a result of con- 
tinually lying in a bed wet with sweat, urine, and other liquids. De- 
cubitus is particularly frequent over the sacrum, and may there attain 
a fearful size, all the soft parts becoming gangrenous down to the 
bone ; it may also occur over the heel, the trochanters of the femur, 
head of the fibula, scapula, or spinous processes of the vertebras, ac- 
cording to the position of the patient. The same thing may be caused 
by badly-applied dressings. This disease is the more unpleasant, as 
it usually comes during other exhausting affections. Although no 



330 GANGRENE. 

disease in which the patient is condemned to long, absolute quiet, is 
entirely exempt from the disagreeable accompaniment of a decubitus, 
still some peculiarly dispose to it, chief among which- is typhus ; in 
patients with septicaemia, decubitus occurs very early, often even after 
three to five days of quiet ; it usually begins with a very circumscribed 
congestion of the skin over the sacrum, while, with proper care, con- 
sumptive patients keep their beds for months or years, without having 
bed-sores. 

This disease is particularly troublesome for the patient, because, 
especially in chronic maladies, it may be accompanied by great pain ; 
in acute cases of typhus and septicaemia, on the contrary, the patients 
sometimes do not feel it at all when they have a very large bed-sore. 
This form of gangrene is particularly dangerous when the exciting 
causes cannot be entirely removed, and it becomes progressive ; the 
prognosis is worse the more exhausted the patient ; not unfrequently 
bed-sore is the cause of death, as it continues to enlarge in spite of 
all treatment, or it may be the origin of a fatal pyaemia. 

Too great tension of the tissue, causing great distention of the 
vessels, and compressing some of them, induces, on the one hand, a 
diminished amount of blood, while the pathological requirements of 
nutriment are increased ; on the other, a coagulation of blood in the 
capillaries from the increased friction. This is the cause of gangrene 
occurring in inflammation, and which we have' already mentioned 
when speaking of phlegmon, but it must not be said that every stasis 
of the blood in the capillaries that may occasionally occur in inflam- 
mation is to be referred to great tension of the tissues, as there are 
also other causes. It would lead me too far to enter on theories, 
especially as you have already heard them in the course on general 
pathology." Moreover, we shall return to this when treating of throm- 
bosis of the veins. 

3. Complete arrest of the supply of arterial blood, which is particu- 
larly due to diseases of the heart and arteries, must also sometimes 
lead to gangrene; in this class belong those cases of gangrene 
called gangrcena spontanea, or oftener gangrmna senilis, from its 
more frequent occurrence in old persons ; this may come in various 
ways and forms. The causes may vary thus: The coagulation of 
blood may begin in the capillaries (marasmic thrombosis as a result 
of debility of the heart, or insufficient conduction through the smaller 
arteries), or as an independent thrombus of the artery, or, lastly, a 
thrombus from embolism ; excessive, continued anaemia also, with 
great consecutive contraction of the arteries and debility of the heart, 
and, lastly, continued spasmodic contraction of the arteries, ma} 7 - in- 
duce gangrene. Gangraena senilis proper is a disease originally oc- 



GANGILENA SENILIS. 33 1 

curring in the toes, rarely in the fingers, as I once saw. There are 
two chief forms: in one of them a brown spot forms on one toe ; it 
soon becomes black, and gradually spreads till the whole toe becomes 
completely dry. In favorable cases a line of demarcation forms at 
the phalango-metatarsal articulation, the toe falls off, and the wound 
cicatrizes. But the mummification may go higher and limit itself in 
the middle of the foot, above the malleoli, in the middle of the leg, 
or just below the knee. In another series of cases, the disease be- 
gins with symptoms of inflammation, cedematous swelling of the toes, 
very great pain, and dark, bluish-red color, which subsequently be- 
comes black ; there are stages of the disease where, by the bluish-red, 
mottled appearance of the skin, we may see that in one place the cir- 
culation is carried on with the greatest difficulty, while elsewhere it 
has already ceased ; this struggle between life and death the French 
have not inaptly compared to death by asphyxia, and termed asphyxia 
locale. In this form of moist, hot gangrene, the disease usually attacks 
several toes at once, and extends to the foot, till in the course of a 
few weeks the entire foot, perhaps also the leg, becomes gangrenous ; 
at the same time decomposition soon begins in the cedematous sub- 
cutaneous cellular tissue, and the danger of absorption of putrid mat- 
ter through the lymphatic vessels is much greater than in the process 
of mummification. The seat of the disease of the arteries that leads to 
spontaneous gangrene varies ; in acute (marasmic) gangrwna senilis, 
the primary coagulation due to feeble circulation occurs in the capil- 
laries and thence extends backward to the arteries. The feebleness 
of the arterial circulation may be due to various causes : 1. To di- 
minished energy of the heart's action ; 2. To thickening of the walls 
of the arteries and contraction of their calibre ; 3. To degeneration 
of the muscular coat of the smaller arteries. In some cases all of 
these causes unite, for, in old persons with feeble heart-action, diseases 
of the arteries are the most frequent ; besides, affections of the heart 
and arteries usually have a common constitutional cause. This is not 
the place to discuss extensively how far rigidity and atheroma of the 
coats of the artery are to be referred to inflammation, or to be re- 
garded as a peculiar disease ; nor can I permit myself to discuss 
further the distinctions of the finer histological points, of which we 
shall have something to say when treating of aneurisms, but will 
simply mention that in old persons the coats of the arteries are often 
thickened, and deposits of chalk form in them to such an extent that 
the whole artery is calcified and the calibre considerably dimininished 
by the thickening of the walls, and the inner surface becomes rough, 
so as to dispose to the fixation of blood-clots. The original qualities 
of the arteries are thus lost to such an extent that they are neither 



332 GANGRENE. 

elastic nor contractile, and hence, partly from the diminished calibre, 
partly from the lack of contractility, the onward movement of the 
blood, already moved less forcibly on account of the feeble action of 
the heart, is very much impeded, so that it is easy to understand how 
coagulation occurs in such cases, especially in parts distant from the 
heart. 

While the cases just described are with some justice termed senile 
gangrene, and their connection with arterial diseases has been gen- 
erally recognized since the time of Dupuytren, there is another form 
of spontaneous gangrene, which occurs in old persons, but is distin- 
guished from the above, because a large portion of an extremity, as 
of the leg as high as the calf or the knee, becomes gangrenous at once 
This takes place as follows : In the chief artery, say the femoral, along 
the thigh or in the hollow of the knee, a firm clot forms and adheres 
to the wall of the vessel by rough prominences on the internal coat, 
due to precedent atheromatous disease, or else forms in sac-like dila- 
tations of the artery and gradually grows by apposition of new fibrine, 
so as not only to fill the calibre of the artery, but to plug up the whole 
peripheral end of the vessel, and even a portion of the central end, by 
the fibrinous clot. The consequence of this stoppage of the artery by 
a thrombus developing on the wall, which gradually arrests the col- 
lateral circulation also, is usually gangrene of the whole foot and part 
of the leg, which is dry or moist according to the rapidity with which 
the clot has developed ; it is occasionally possible to trace the growth 
of the thrombus by the spread of the gangrene. Not long since I 
observed an old man, who was taken into the hospital for spontaneous 
gangrene of the foot. He was so thin and the arteries were so rigid 
that the pulsations of the femoral could be distinctly followed into the 
hollow of the knee. Subsequently the gangrene progressed, and at 
the same time the pulsation in the lower part of the artery ceased. 
About a fortnight later, shortly before death, when the gangrene had 
advanced to the knee-joint, the pulsation had ceased at Poupart's liga- 
ment. The autopsy confirmed the diagnosis of complete arterial 
thrombosis. The gangrenous leg was so completely mummified that I 
cut it from the body, and, to preserve it from further destruction and 
worms, varnished it. It is still in the surgical museum at Zurich. 

Another case of arterial thrombosis is where the primary stoppage 
of the artery is caused by an embolus. A clot of fibrine, in endocarditis 
or detached from an aneurismal sac, may become wedged in an artery 
of one of the extremities ; this induces further deposit of fibrine. Of 
late, there is a tendency to refer most cases of softening and desiccation, 
as of the brain, spleen, etc., to such emboli. In our clinic we saw a 
very interesting typical case of this variety. Six weeks after confine- 



ERGOTISM. 333 

ment, a young woman had great swelling of the left leg, which was 
soon followed by a dark-blue color of the skin, and complete putrefac- 
tion of that part of the body ; there was general septic poisoning 
when the patient entered the hospital. As there was no excessive 
anaemia, and no disease of the arteries could be discovered, I made the 
diagnosis of endocarditis with fibrinous vegetations on the mitral valve, 
and detachment of one of these vegetations, with its lodgment at the 
bifurcation of the left popliteal artery. I held to this diagnosis, al- 
though no abnormal murmur could be discovered, for it is well known 
that some cases of endocarditis run their course almost without symp- 
toms ; the rapid putrefaction of the leg must have had a sudden cause. 
As no line of demarcation formed, and the general condition daily 
became worse, we could have no hopes of saving life by amputating ; 
death took place about twelve days after the first symptoms of gan- 
grene ; the autopsy fully confirmed the diagnosis. It seems remark- 
able that no collateral circulation should develop in such cases, as it 
does after ligation of the femoral artery. I can only explain this on 
the supposition that in endocarditis the heart's action is weakened, 
and consequently the pressure of the blood is insufficient to dilate the 
smaller collateral arteries. 

Yery rare are the cases where from excessive anaemia the arteries 
are so much contracted that but little blood circulates through the 
smaller ones, and the nervous excitation of the heart is so slight that 
its contractions are incomplete. Cases of spontaneous gangrene from 
this cause are more frequent in slender chlorotic females than in men ; 
the patients, who are generally young, often suffer from rigidity of the 
hands and feet, fainting-fits, and fatigue. This disease appears to be 
more frequent in France than in Germany or England. There is an 
excellent work on the subject by Raynaud r , entitled " De Pasphyxie 
locale et de la gangrene symetrique des extremites," 1862. As im- 
plied by the title, the gangrene is usually symmetrical in the two 
limbs. I have only seen one such case ; a young, very anaemic man, 
without any apparent cause, had first gangrene of the tip of the nose, 
then of both feet. After suffering for months, he died ; as on the pa- 
tient, so on the cadaver, I could find nothing morbid beyond the ex- 
cessive, inexplicable anaemia. 

The form of gangrene seen from eating spurred rye is referred to 
permanent spasmodic contraction of the smaller arteries ; experience 
shows that this substance induces contraction of the organic muscular 
fibres, especially of those of the uterus, and it is supposed of the 
uterine arteries also. 

Spurred rye, secale cornutum, is a diseased grain growing in the 
ear of rye (secale cereale), in which is developed a peculiar material, 



334 GANGRENE. 

ergotin. If bread be made from such grain, persons eating it are 
affected with peculiar symptoms, which are comprised under the name 
ergotismus or raphania. As the above disease of the grain is usually 
limited to certain regions, it may be readily understood that the dis- 
ease should occur epidemically in men and beasts. It has been known 
for a long time, but the first accurate descriptions are of an epidemic 
in France in 1630. The disease seems to have occurred rarely in 
Germany, England, or Italy. Of late it hardly ever occurs, probably 
because the diseased grain is better known and is no longer used for 
food, and because less of the grain is grown since potatoes have come 
into common use. From former descriptions, various forms and 
courses of the disease may be distinguished, of which sometimes one 
and sometimes another prevailed in the different epidemics ; possibly 
the poison is not always the same, or is at least of variable intensity. 
In the acute cases, the patients were soon attacked with severe gen- 
eral cramps, and death resulted in from four to eight days ; cramps 
only occur occasionally ; at the same time, and previously in the pro- 
dromal stage, there are great itching and crawling in the skin, but par- 
ticularly in the hands ; there is also a feeling of deafness, of anaesthe- 
sia in the ends of the fingers, rarely moist gangrene of the skin, then 
of whole extremities. In more chronic cases, the result is usually 
favorable, although several fingers or toes may be lost. 

4. We have still to speak of several forms of gangrene whose 
causes are not exactly known, in which probably several influences 
unite. Among these is so-called water-canker, noma, a spontaneous 
gangrene of the cheeks, especially common in children, which is most 
frequent in cities along the Baltic, and more rare inland. Very puny 
children, living in cold, damp dwellings, are particularly prone to this 
disease, in which, without any known cause, a gangrenous nodule 
forms in the middle of the cheek or lip and spreads rapidly till the 
child finally dies of exhaustion. It is doubtful whether this is due to 
anaemia with feebleness of the heart, to miasmatic influence, or to some 
peculiar disease of the blood. In occasional remarks about septi- 
caemia, we have already stated that certain morbid states of the blood 
predispose to gangrene. Under this cause we must class the cases 
occurring after typhus, intermittent and exanthematous fevers, in 
diabetes mellitus, morbus Brightii, etc. After and during these dis- 
eases, gangrene of the tip of the nose, of the ear, cheeks, hands, and 
feet, occurs ; and in rare cases an exanthema of the skin may pass into 
gangrene. In such cases we may consider that the miasma which has 
induced the constitutional disease also influences the occurrence of 
the gangrene ; and, on the other side, there seems reason for the idea 
that these cases are mostly the result of feeble action of the heart. 



TREATMENT OF GANGRENE. 335 

induced by the long illness, which proves insufficient to carry the 
blood to the remote parts of the body with sufficient energy ; accord- 
ing to this view, this gangrene would be due to marasmic capillary 
thrombosis. Doubtless various circumstances act more or less promi- 
nently in individual cases, so that no definite etiology can be given 
for these rare forms of gangrene from internal causes. I may also 
mention that stomatitis, from excessive use of mercury, also has a 
great tendency to gangrene. We shall hereafter speak of a peculiar 
form of gangrene of wounds, the so-called hospital gangrene}' 1 



There are certain important prophylactic rules for the prevention 
of gangrene, especially of decubitus and other forms due to pressure ; 
even gangrene from inflammation may sometimes be prevented, by re- 
lieving the great tension of the tissue and the venous congestion by 
an incision made at the proper time. Be constantly on your guard 
against bed-sores in all diseases at all disposed to decubitus ; turn 
your attention to this point early : a well-stuffed horse-hair mattress is 
the best sick-bed ; the sheets placed over it should always be kept 
smooth, so that the patient shall not lie on wrinkles. As soon as any 
redness appears over the sacrum, you should be doubly careful about 
the passages of urine and feces, so that the bed may not be wet. Let 
a lemon be cut and the reddened spot rubbed daily with the fresh juice 
from the cut surface. If there be excoriation over the sacrum, place 
the patient on a ring cushion, or, if possible, on a caoutchouc, air, or 
water cushion. The excoriation may be painted with nitrate of silver, 
or covered with leather spread with lead-plaster. If the decubitus be 
gangrenous from the first, and this begins to extend, we should resort 
to the ordinary treatment of gangrene, of which we shall speak pres- 
ently. 

The local treatment of gangrene has two chief objects : 1. To pro- 
mote detachment of the gangrenous parts by exciting active suppura- 
tion, which is accompanied by arrest of the gangrene ; 2. To prevent 
the gangrenous parts decomposing, and thus acting injuriously on the 
patient, and infecting the chamber too much. 

For the first indication, moist warmth in the form of cataplasms 
was formerly employed. But I cannot find that they are peculiarly 
efficacious in these cases. If the gangrene be moist and the gangre- 
nous parts are much inclined to decompose, this would only be favored 
by the application of cataplasms ; for the detachment of a dry eschar, 
which does not smell badly, and when the line of demarcation is al- 
ready formed, it is hardly worth while to hasten the process a little 
by warmth. Hence I prefer covering the gangrenous parts and the 



336 GANGRENE. 

borders of the healthy tissue with compresses or charpie, soaked in 
chlorine-water, and thus in moist gangrene I also diminish the bad 
smell of the decomposing substances. For the same purpose, we may 
use creosote-water or carbolic acid, or dilute purified pyroligneous 
acid, very strong alcohol, spirits of camphor, or oil of turpentine. 
Charcoal-powder absorbs the gases from the decomposing substances, 
but, as it soils the parts very much, it is perhaps too little used. Other 
powerful antiseptics are acetate of alumina (alum 3 v, plumbum aceti- 
cum, J j> aqua, g> 1), and coal-tar with plaster ; both remedies are 
very serviceable, but, like all similar ones, must be freshly applied 
several times daily to remove entirely the smell of the decomposing 
parts. Of late, permanganate of potash (gr. x to § i water) has been 
greatly praised as a local antiseptic and disinfectant ; I have made 
several trials of it, but have found it far inferior to the remedies pre- 
viously mentioned. Concentrated solutions of carbolic acid in olive- 
oil (say 3 ij to lb 1) cause symptoms of poisoning (olive-green urine), 
hence they should be used carefully. As soon as the gangrenous 
mass has become somewhat detached, the shreds should be removed 
with the scissors, without cutting into the healthy parts ; this is par- 
ticularly important in gangrene of the subcutaneous cellular tissue, 
which is often extensive, as after infiltration of urine ; at the same 
time the local antiseptics should be continued till healthy granulations 
arise. Led by the anatomical conditions in spontaneous gangrene, it 
has been advised to break up the coagulation of blood, by stroking 
and rubbing the limb ; from the pain and swelling of the parts, this is 
rarely practicable ; in cases where I have had it done, it has had no 
effect on the progress of the gangrene. 

If the gangrene affect a limb, as in the various forms of sponta- 
neous and senile gangrene, I strongly urge you not to do any opera- 
tion till the line of demarcation is distinct. If there be merely gan- 
grene of single toes, leave their detachment to Nature ; if the whole 
foot or leg be affected, do the amputation so that it may be merely 
an aid to the normal process of detachment, i. e., on the borders of 
the healthy parts you try to dissect up only enough skin to cover the 
stump, and saw the bone as near as practicable to the line of demar- 
cation. Thus you will occasionally succeed in avoiding a new out- 
break of the gangrene, and in saving your patient's life. If the patient 
dies before a distinct line of demarcation has formed (as is frequently 
the case), you need not reproach yourself for having neglected am- 
putation, for you may rest assured that the patient would have died 
even sooner if amputation had been performed. The prognosis in 
gangrene from internal causes (as the older surgeons termed it) is 
generally bad. 



TREATMENT OF GANGRENE. 33^ 

The internal treatment should be strengthening, in some cases 
even stimulant. Nourishing food, quinine, acids, and occasionally a 
few doses of camphor, are proper. The severe pain in senile gan- 
grene often .calls for large doses of opium, or subcutaneous injection 
of morphine. For gangrene in stomatitis, after poisoning by mercury, 
we have no decided antidote ; the use of the mercurial should be at 
once stopped; if mercurial salve has been employed, the patient 
should be bathed, placed in a fresh, airy chamber, provided with clean 
body and bedclothes, and have a gargle with chlorate of potash or 
chlorine water. Nor have we any antidote for ergotin, which causes 
raphania ; emetics, quinine, and carbonate of ammonia are chiefly rec- 
ommended. We could only put off the continued absorption of putrid 
matter into the blood, by amputation ; but we have already mentioned 
that this is a very precarious remedy in spontaneous gangrene. 

22 



CHAPTER XIII. 

ACCIDENTAL TRAUMATIC AND INFLAMMATORY 
DISEASES, AND POISONED WOUNDS. 



LECTURE XXIV. 

I. Local Diseases which may accompany Wounds and other Points of Inflammation: 
1. Progressive Purulent and Purulent Putrid Diffuse Inflammation of Cellular 
Tissue. — 2. Hospital Gangrene, Ulcerative Mucous-salivarv Diphtheria, Ulcerative 
Urinary Diphtheria. — 3. Traumatic Erysipelas. — L Lymphangitis. 

Gentlemen : When speaking of traumatic inflammation, I told 
you that it did not extend beyond the bounds of the injury, and that 
this was only apparently the case when we could not accurately ex- 
amine the injured part. I still maintain the truth of this. But we 
have already added that, from various accidents, either immediately 
after the injury, as in contused wounds, there may be very severe 
progressive inflammation, with putrefaction, or that, later, secondary 
inflammations may develop around the already granulating wound 
from causes which we mentioned at the time (Lecture XIII.). I must 
now tell you that still another series of peculiar, partly inflammatory, 
partly gangrenous processes occur in the wound, which cause severe, 
usually feverish, constitutional diseases. Some of the latter may also 
occur without any thing peculiar being observable in the wound. 
Lastly, substances may enter a wound already existing, or at the 
time of its occurrence (as from the bite of a poisonous or diseased 
animal), which may induce both severe local inflammation and gen- 
eral blood-poisoning. In this chapter I shall speak of all these 
things ; I will try to give you a general view of them. We shall 
speak first of the local symptoms which accidentally accompany a 
wound, or an inflammation due to other causes. 



HOSPITAL GANGRENE. 339 

I. LOCAL DISEASES WHICH MAY ACCOMPANY WOUNDS AND OTHER 
POINTS OF INFLAMMATION. 

1. For the sake of completeness, we here mention again progres- 
sive suppurative and sanio-purulent diffuse inflammation of the cellular 
tissue. Putrid matters which form on fresh wounds from gangrene 
of the surfaces of the wound, and may diffuse rapidly in the meshes 
of the cellular tissue, occasionally cause, on the second, third, or fourth 
day, those forms of inflammation of the cellular tissue that are char- 
acterized by rapid decomposition of the inflammatory product and by 
rapid extension. If the patient survives the demarkation of such a 
phlegmon, the process always ends with necrosis of the infiltrated 
cellular tissue and panniculus adiposus. The same thing occurs in 
fibrinous (diphtheritic) phlegmon. Both processes are usually ac- 
companied by severe constitutional symptoms. If suppuration has 
already begun, as long as the wound is open, phlegmonous inflam- 
mation may spread around the wound from mechanical irritation, 
foreign bodies, great congestion, retention and decomposition of 
pus in the recesses of the wound, or infection of the wound with 
phlogogenous substances of various sorts (Lecture XXL). 

2. Hospital Gangrene, Gangroma JVbsocomialis; Pourriture des 
Hopitaux. — I will first describe the disease, then add a few remarks 
about the etiology. At a certain time we notice, especially in hos- 
pitals, that a number of wounds, as well those from recent operations 
as those that were granulating and cicatrizing, without known cause, 
become diseased in a peculiar manner. In some cases the granulat- 
ing surface changes partially or entirely to a yellow smeary pulp, 
which may be washed off from the surface, but more deeply it is 
firmly adherent. This metamorphosis extends not only to the granu- 
lating surface, but to the surrounding skin which was previously 
healthy, which becomes rosy-red ; this also assumes a smeary yel- 
lowish-gray color, and in from three to six days the surface of the 
original wound almost doubles. The increase in depth is less in the 
so-called palpous form of hospital gangrene. In other cases a fresh 
wound, or a granulating surface, rapidly assumes a crater shape, 
excretes a sero-putrid fluid, after the removal of which the tissues lie 
exposed. The surrounding skin is slightly reddened. The progress 
of this molecular disintegration to thin ichor is usually in sharply-cut 
circles, so that the wound may acquire a horseshoe or trefoil shape. 
This ulcerous form of hospital gangrene progresses more rapidly than 
the pulpous, and extends with especial rapidity in depth. Although 
both of the above forms occasionally occur separately, they are 
also seen in combination. I have seen the pulpous form oftener 
than the ulcerous, but acknowledge that my individual experi- 
ence of diphtheria of wounds is based on a small number of ob- 



340 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

servations. Hospital gangrene does not attack chiefly large wounds, 
but rather insignificant injuries, such as leech-bites, cup-cuts, even 
the portions of skin denuded by a blister, while it never occurs on an 
uninjured part of the skin. The resemblance to diphtheritic inflam- 
mation of the mucous membranes is mentioned by some authors. But 
after seeing a wound infected from a diphtheritic mucous membrane, 
I am convinced that diphtheria and hospital gangrene are two differ- 
ent processes. A wound attacked by diphtheria is covered with 
thick fibrinous rinds ; the entire wound becomes infiltrated and the 
surrounding parts intensely erysipelatous ; then a large part of the 
infiltrated tissue becomes necrosed and breaks down or falls off in 
shreds. But we do not see the daily progress of pulpous degenera- 
tion, forming round figures on the margins of the wound, which are 
puffy, very sensitive, and inclined to bleed, as is so common in hos- 
pital gangrene. - It is well known that after diphtheria of mucous 
membranes paralysis is not unfrequent; but this has not been ob- 
served after hospital gangrene. In the latter disease there are at 
the same time constitutional symptoms : at first the fever is not gen- 
erally severe, but there is more or less gastric affection ; the tongue 
is coated, there is inclination to vomit, and general depression. 
The disease may prove dangerous to old or debilitated persons, es- 
pecially if it eats away small arteries and causes arterial haemorrhage. 
The large arteries often resist hospital gangrene wonderfully. I 
once saw a man, for whom an inguinal abscess had been opened, at- 
tacked by the pulpous form of the disease ; the skin of the groin to 
about the size of the hand was destroyed; the disease had ad- 
vanced so deep that about an inch and a half of the femoral artery 
lay exposed in the wound, and could be distinctly seen pulsating. 
I detailed a nurse to stay with the patient constantly, and to make 
instant compression if bleeding should occur, as it might at any mo- 
ment. The pulp was thrown off, the wound granulated rapidly, and 
after a long time complete recovery took place without haemorrhage. 
The erysipelatous redness accompanying diphtheritic phlegmon and 
hospital gangrene is occasionally as sharply bounded and desqua- 
mates as much as in erysipelas about wounds otherwise healthy ; but 
it has not the same tendency to spread. The constitutional septic 
poisoning is worse in diphtheria than in hospital gangrene. 

Views as to the causes of hospital gangrene vary ; this is chiefly 
because many living surgeons have had the good or bad fortune never 
to have seen the disease ; thus in Zurich it has never been seen. In 
his maxims on military surgery Stromeyer states, as a young physician 
in the Berlin Charite, he had only seen one case of hospital gangrene. 
Surgeons who have not seen this disease, or have only seen sporadic 



HOSPITAL GANGRENE. 341 

cases, think it is due to gross neglect, dirty dressings, etc., and regard 
it as little more than an ulcer of the leg that has superficially become 
gangrenous from dirt and neglect. Other surgeons suppose that hos- 
pital gangrene is, as the name would indicate, a disease peculiar to 
some hospitals, and that its occurrence is only promoted by neglect 
of the dressings. Lastly, a third view is that this form of gangrene is 
due to epidemic influences, and that its name is in so far incorrect as 
it occurs outside and inside of hospitals at the same time. In the 
hospitals it probably spreads by inoculation, for I do not doubt that 
matter can be carried from gangrenous to healthy wounds by forceps, 
charpie, sponges, etc., and there excite the disease. Von Pitha and 
Fock have expressed the belief that it is an epidemic-miasmatic dis- 
ease. In the surgical clinic at Berlin with Fock I observed an epi- 
demic, while the disease was seen not only in other hospitals in Ber- 
lin, but in the city, in patients who could not be proved to have had 
any thing to do w T ith a hospital. The disease appeared very suddenly, 
and entirely disappeared in a few months, although the treatment of 
the wounds had not been at all changed, nor could any changes be 
made in the hospital itself. This seems to show that the causes do 
not lie in the hospital itself. Epidemic hospital gangrene might oc- 
cur from certain small organisms, which are rarely developed, which, 
like a ferment, induce decomposition in the wound and granulating 
tissue ; hence I should preferably compare this disease of wounds 
with blue suppuration, which causes no injury to the wounds, but, 
according to LiXcJce, like blue milk, is caused by small organisms and 
can infect other wounds. The requirements for the growth of these 
small bodies are probably particularly favored by certain atmospheric 
influences ; hence the disease spreads epidemically. There is no 
doubt that in the pulp of every hospital gangrene micrococci and 
streptococci are just as frequent as in the secretion of simple diph- 
theritic wounds. But it has not been proved that they were in the 
tissue before it was destroyed, that they grew in it, or broke it 
down into pulp ; nor has it been shown that this is a peculiar va- 
riety of micrococcus. But it is certain that the transfer of hospital 
gangrene pulp or putrid matter to healthy wounds usually (always, 
according to Fischer) induces hospital gangrene, and this is very 
important in practice. From my recent experience in the Vienna 
General Hospital, I am more and more convinced that this disease 
results from specific causes, entirely independent of pyaemia, septi- 
caemia, erysipelas, and lymphangitis, although it may be followed 
by either of these diseases. 

The first point in the treatment is strict isolation of the patients, 
who should have special nurses, dressings, and instruments. If this 



342 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

does not entirely prevent the spread of the disease, as the contagion 
may possibly be carried by the air from a diseased to a healthy 
wound, still experience shows that it interferes with the spread. In 
some epidemics in military hospitals it was necessary entirely to va- 
cate certain localities. Locally we should apply strong chlorine- 
water, or spirits of camphor or turpentine, to these wounds. Some- 
times painting the part every two hours with tincture of iodine acts 
well, or solution of acetate of alumina applied on a compress till the 
wound becomes clean; but the solution should not be too concen- 
trated, and its application should be stopped when the process ceases 
to spread. If this also prove ineffectual, it has been recommended 
to burn the wound down to the healthy tissue, so that the slough 
shall remain attached six or eight days, as in a healthy wound. I 
find it just as effectual to cauterize the wound with fuming nitric 
acid or carbolic acid, but these cauterizations also should extend to 
the healthy borders of the wound, and be repeated till the slough 
remains adherent. The general treatment should be strengthening, 
or even stimulant. The fever occurring in hospital gangrene is due 
to reabsorption of putrid matter, and does not differ from other 
forms of putrid fever. 

The pulpous phagedenic gangrene above described is especially 
apt to occur in wounds of the mouth or urinary bladder, even with- 
out any external source of infection. I mention this here because 
these diseases are doubtless allied to phagedenic diphtheria, al- 
though, from their limitation to certain parts of the body, they more 
properly belong to special surgery and the clinic. After extirpation 
of large portions of the tongue and resection of the lower jaw, I 
have sometimes seen a rapid pulpy breaking down of the wound fol- 
lowing hard and extensive infiltration of the cellular tissue ; here 
there is a combination of diphtheritic phlegmon with phagedenic 
ulceration. Most of these cases ended fatally from septicaemia ; 
others recovered after the whole cellular tissue had become necrosed 
and been thrown off by free suppuration. Although mucus and 
saliva coming in contact with these wounds may have no phlogoge- 
nous or septic qualities of their own, putrid ferments may be mixed 
with them, such as are occasionally found in the coating on the gums 
and between the teeth of patients who do not clean their mouths ha- 
bitually, or neglect this on account of painful ulcers in the mouth. 
So this ferment will be carried to wounds in the mouth by the mu- 
cus and saliva, thus justifying the name mucous salivary diphtheria. 
This disease only threatens the patient during the first five days 
after operation ; only recent wounds in the mouth are infected by 
the ferment in question ; if good granulations have once developed, 



HOSPITAL GANGKENE. 343 

this diphtheria does not occur, unless there be infection from with- 
out, or the wound be mechanically injured and the granulations 
partly destroyed. In this disease the constitutional symptoms may 
be very severe, and the patients are particularly subject to sudden 
collapse, which is the more dangerous as, from the impairment of 
nutrition which has often gone before, the patients are usually much 
debilitated. 

After operations for stone, urethrotomy, vesico-vaginal fistula, 
or ectopia vesicae, pulpous breaking down of the edges of the wound, 
with fibrinous coating of the walls of the bladder or of the vagina, 
is not rare, especially when the urine is alkaline. As this disease is 
associated with decomposition of the urine, it is called urinary diph- 
theria. This form of diphtheria is the mildest of those above men- 
tioned, from having little tendency to spread, and running its course 
without constitutional symptoms, if the wound is kept clean. Rarely 
the mucous membranes break down, but more frequently the process 
becomes a purulent retroperitonitis, which becomes a peritonitis 
and causes death. Diphtheritic inflammation of the vagina also 
may spread as superficial suppuration to the inner surface of the 
uterus, and thence through the oviducts to the peritoneum ; this 
suppurative peritonitis also is usually fatal. Under such circum- 
stances I have never seen fibrinous inflammations. In the latter 
cases, which unfortunately are not rare after confinement, but do not 
often occur after operations for vesico-vaginal fistula, severe consti- 
tutional symptoms are early manifested. 

In the pulp from mucous-salivary and from urinary diphtheria 
micrococci and streptococci are constantly found ; they are just as 
regularly found in the coating of the gums and tongue, and in urine 
which has become alkaline, but seem to develop with particular ra- 
pidity in this pulp. The contagious principle of this pulp has not 
yet been separated from the micrococcus ; so we may suppose the 
latter has in or on it the contagious material. There is no proof 
that micrococci from any source can excite this process ; but many 
observations tend to show that these vegetations take up contagious 
substances very readily, and so become vehicles of contagions and 
ferments. If we inoculate the cornea of a rabbit with a fluid con- 
taining micrococci, the interesting experiments of JVassiloff, JEberth, 
Leber, Stromeyer, Dolscherikow, Orth, Frisch, and others show that 
the coccus grows to a certain point, and in some cases (when unac- 
companied by any peculiarly injurious substances) causes irritation, 
chiefly mechanically, by separating the corneal lamellae, so that the 
coccus colony gradually becomes enveloped in pus, and then is 
thrown off with the pus ; but in other cases (if the inoculated mat- 



344 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

ter has very deleterious properties) the whole cornea may become 
gangrenous in twenty-four hours, and the growth of the coccus 
hardly be as great as in the first instance. Lastly, cases occur where 
the coccus growth induces no reaction in the cornea, but disappears 
without leaving a trace; this is even the rule in inoculating the 
cornea of the dog. 

Fig. 66 a. 




a, Fungus from the cornea of a rabbit ; coccus proliferation between the lamellae of the cornea, in- 
duced by inoculation ; slightly magnified, b, One point of a, magnified 600. After Frisch. 



From this it follows that the intensity and nature of inflamma- 
tions induced by such contagions do not depend on the coccus pro- 
liferation itself, but on the injurious qualities of the matter conveyed 
with the coccus. 

I thought you should be told these things, so that you would 
have some knowledge about processes which are now so much dis- 
cussed. I recommend for your special study the excellent mono- 
graph on hospital gangrene by C. Heine. 

3. Erysipelas traumaticum. Erysipelas, as previously mentioned 
(page 281), is classed among the acute exanthemata, and is charac- 
terized by a diffuse swelling, rosy redness of the skin, and pain, as 
well as by the accompanying fever, which is usually severe. Erysip- 
elas has a peculiar relation to the other exanthemata ; on the one 
hand, because it often accompanies wounds, although it may appar- 
ently come spontaneously ; on the other hand, because it does not 
generally spread by such an intense contagion as measles, scarlatina, 
etc. ; lastly, also because, when one has had this disease, he is not 
only not safe from another attack of it, but in some cases is even pecu- 
liarly predisposed to it. As I dare hardly assume that you have al- 
ready studied skin-diseases carefully, we will here briefly review the 
symptoms of this disease. 

Its commencement may vary by the fever preceding the exanthema, 



ERYSIPELAS TRAUMATICUM. 345 

or by their simultaneous appearance. Suppose you have a patient 
with a suppurating wound of the head, and after he has been previ- 
ously well, and the wound was healing nicely, you find him with high 
fever, which may have been preceded by a chill ; you examine the pa- 
tient, and can find nothing but some gastric derangement, as evinced 
by a coated tongue, bad taste in the mouth, nausea, and loss of appe- 
tite. This state is present at the onset of so many acute diseases 
that you cannot at once make a diagnosis. Besides the possibility of 
an accidental complication with any acute internal disease, you would 
think of phlegmon, lymphangitis, and erysipelas. Perhaps twenty-four 
hours later you find the wound dry, discharging a little serous secre- 
tion ; for some distance around there are swelling, redness, and pain, 
or the granulations are large, swollen, and croupous ; the redness of the 
skin is of a rosy hue and everywhere sharply bounded y the fever is 
still tolerably intense ; now the diagnosis of erysipelas cannot be mis- 
taken, and we are well content that we have to deal with a disease 
which, although not free from danger, is one of the less dangerous of 
the traumatic diseases. In a second series of cases the erysipelas ap- 
pears with the fever. We may for a brief period doubt whether the 
case be one of lymphangitis, inflammation of the subcutaneous cellular 
tissue, or of erysipelas, but the course of the disease will soon show 
this ; the extent that the erysipelatous inflammation of the skin has 
the first day rarely remains the same, but it usually spreads farther 
and farther, in such a way that the rounded, tongue-shaped, project- 
ing borders of the inflamed skin are always sharply bounded, and we 
can accurately follow its removal from one side to the other ; in many 
cases the redness advances like fluid in bibulous paper. Thus the 
process may extend from the head to the neck, thence to the shoul- 
ders, or the anterior part of the trunk, or even pass down the arm, and 
finally may even reach the lower extremities. Pfleger has observed 
that the mode of extension of wandering erysipelas is almost always 
the same, and is probably due to the flow of certain fluids (lymph), 
which again depends on the arrangement of the filaments of the cutis. 
As long as the erysipelas spreads in this way, the fever usually remains 
at the same height, and thus old or debilitated persons are readily 
exhausted. Most cases last from two to ten days ; it is rare for one to 
continue over a fortnight ; the most protracted case I have seen was 
one lasting thirty-two days and recovering. In this erysipelas ambulans 
or serpens you will notice that the same grade of inflammation of the 
skin only continues a certain length of time in one place, so that when 
the erysipelas advances, the whole surface is not inflamed at once, 
but only a part at a time is at the acme of the local inflammation. 
After the inflammation has remained at the same point about 



346 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

three days, the redness grows less, the skin desquamates, partly as a 
bran-like powder, or in scales and tags of epidermis. In some cases, 
even at the commencement of the erysipelas, the epidermis rises in 
vesicles, which are filled with serum {erysipelas bullosuni). But this 
erysipelas is not a peculiar form of the disease ; it only indicates rapid 
exudation. We not unfrequently see vesicles appear on the face in 
erysipelas, while on the rest of the body the disease has the usual 
form. If erysipelas attacks the scalp, the hair often falls, but grows 
again quickly. According to my experience, the disease is most fre- 
quent on the lower limbs, then on the face, upper extremities, breast 
and back, head, neck, and belly. This scale of frequency probably 
depends on the proportionate numbers of injuries in the different 
parts of the body. 

Erysipelas, like other exanthemata, may be accompanied by vari- 
ous internal diseases, as pleurisy, and erysipelas capitis by meningitis ; 
but, on the whole, these complications are rare, and when they occur 
are usually a result of the disease advancing to the deeper parts. 

The course of erysipelas is usually favorable. Of one hundred and 
thirty-seven cases of the uncomplicated disease, which I observed in 
Zurich, ten died ; children, old persons, and patients debilitated by 
previous disease are most endangered, and, according to my experi- 
ence, they usually die of exhaustion from the continued fever ; on 
autopsy, we find no remarkable change of any organ that can be re- 
garded as the cause of death. Cloudy swelling and partial granular 
degeneration of the liver, kidneys, and epithelium, and softness of the 
spleen, are found in cases of fatal erysipelas, as after all intense blood- 
diseases. The nature of erysipelas is not fully understood, as its cause 
and the mode of its progress are not quite clear. Dilatation of the 
capillaries of the cutis, serous exudation in the tissue itself, and an 
active development of the cells of the rete Malpighii are all we can 
find anatomically. The disease rarely extends to the subcutaneous 
cellular tissue ; it is true, this swells enormously in some places, as 
in the eyelids and scrotum, being greatly saturated with serum ; but 
in most cases this oedema recedes without any sequelae. In rare cases 
this oedema attains such a grade that, as a result of the great distention 
of tissue, the circulation of blood is arrested, and the parts (as the eye- 
lids) may become wholly or partly gangrenous. Should all the skin 
of an upper or lower eyelid be lost in this way, it would cause great 
deformity ; but usually only small portions mortify, and, in the upper 
lid particularly, the skin is so plenty in most persons that the defect 
is subsequently but little noticed. In other cases, after the subsi- 
dence of the erysipelatous inflammation, there remains a swelling of 
the subcutaneous tissue, in which we may distinctly feel fluctuation, 



ERYSIPELAS TRAUMATICUM. 347 

and by incision may evacuate pus. Microscopic examination of skin, 
affected with erysipelas shows only more or less infiltration of the 
cutis and subcutaneous tissue. 

The causes of erysipelas evidently vary ; that occurring without a 
wound, spontaneous erysipelas capitis, is said to come most frequently 
after catching cold. Some old persons are said to have this disease 
every year, in spring or autumn ; psychical influences are also blamed 
for it, especially terror, particularly in women during their menses. 
I cannot vouch for the latter, but think it may belong to medical 
traditions. Disturbances of digestion are also regarded as causes. 
I am very skeptical of all the views which are not based on accurate 
observation, but rest on tradition; indeed, I consider it doubtful 
whether erysipelas ever occurs without having started from a wound 
or some point of inflammation already existing. 

From what I have seen of erysipelas traumaticum, my idea con- 
cerning it is as follows : I consider the local affection as an inflamma- 
tion of the cutis, in which the inflammatory irritation gradually 
spreads through the lymphatic net-works ; the way in which the in- 
flammatory redness spreads and is sharply bounded shows positively 
that the process is limited to the vascular districts ; by close observa- 
tion we may see that very often, close to the border of the redness, 
there forms a red, round spot, at first circumscribed, which soon 
unites with the previously-reddened portions of skin ; these newly- 
forming red spots evidently represent vascular districts ; we see 
something similar when we inject the skin through an artery ; then, 
too, the color from the injection first appears in spots, and only unites 
when heavy pressure is made on the syringe ; now, as the venous and 
lymphatic districts in the skin are to some extent analogous to the 
arterial, the irritating poison causing the dilatation of the blood- 
vessels might circulate in one of these tracts. The arterial and 
venous tracts in the cutis have few connecting branches parallel to the 
surface, while the lymphatic vessels have very many, and but few 
branches going down into the subcutaneous tissue ; thus the exciting 
poison may readily spread superficially in the cutis, like liquid in bibu- 
lous paper, but it also enters the subcutaneous lymphatics, and often 
causes inflammation there, as well as in the neighboring lymphatic 
glands, striated redness of the skin, and swelling of the adjacent 
lymphatic glands. When I here speak of a septic or other similar 
poison as a cause of erysipelas, I refer only to traumatic erysipelas, 
for I think I have satisfied myself by observation that this is always 
of toxic origin. Concerning the nature of this poison, I may say : 
1. It is chiefly blood mixed with decomposing secretion from the 
wound that induces erysipelas, which then appears the second or 



348 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

third day after the injury or operation. 2. There is probably a dry, 
dust-like substance, which, coming on the wounds, whether fresh or 
granulating, causes erysipelas ; this substance clings especially to 
sponges and dressings. I have often observed that patients operated 
on after each other, under the same circumstances, in the same 
operating-room, all had erysipelas on the fresh wounds a few hours 
after the operation, without retention of secretion from the wound, 
although they lay in perfectly separate wards of the hospital. Ery- 
sipelas thus becomes domesticated in the hospital ; the infecting sub- 
stance may be transported on the clothes of the surgeons making the 
dressings ; it may adhere to instruments, beds, or even to the walls. 
The more accurately I examined the cases of erysipelas in the Zurich 
hospital, and in my clinic in Vienna, the more evident was its occur- 
rence in groups — an occurrence entirely independent of all other 
morbid influences outside of the hospital. From statistics during 
two years, supported by contributions from the physicians of the 
Canton Zurich, I have found that during that time erysipelas had not 
occurred epidemically in the country or city, but that, like other 
acute diseases, it was particularly frequent in autumn and spring ; 
hence erysipelas epidemics in hospital must depend on circumstances 
that are to be sought in the hospital itself, and which I have already 
indicated. Here arises the question whether the poison which excites 
erysipelas is always the same, whether it is specific. This cannot be 
accurately answered : in its favor is the fact that the form of the cu- 
taneous inflammation induced is always the same, although varying 
in intensity and extent ; against it we may say that erysipelas is 
probably caused by various kinds of putrefaction, by miasma, per- 
haps also by some animal poisons. Possibly in all of these poison- 
ous substances there might be one certain material which induced 
erysipelas, particularly a variety of material, which had a specific affin- 
ity for the lymphatic vessels of the skin ; it must be acknowledged 
that, under certain circumstances, existing at some particular time, 
such a material may develop more readily and extensively than at 
other times. It has often been asserted, and of late more particu- 
larly by Orth, that erysipelas extends by micrococcus vegetation 
from the wound to the skin. Although the spread and reproduction 
of the erysipelas contagion much resemble those of a ferment, there 
is as yet no proof that in erysipelas the micrococcus is the bearer of 
such a ferment, still less that it is only micrococcus. I do not up- 
hold the correctness of this view. I have sometimes found coccus 
and streptococcus in the serum of erysipelas vesicles, but they are 
also found in blisters from burns or sweating, in small-pox pustules, 
etc. ; and this is no proof that these diseases are due to micrococ- 



ERYSIPELAS TRAUMATICUM. 349 

cus. It is doubtful whether the suppurations induced in rabbits by 
inoculation with the serum from erysipelas blisters is identical with 
the erysipelas of man. The most recent work on erysipelas, by 
LulwmsJcy, shows the near relation of micrococcus to erysipelas ; 
T can confirm his observations from others made at my clinic by 
JEhrlich ; but interesting as these are, they cannot settle the vexed 
question as to the etiology of erysipelas. The disease always begins 
with a rapidly-increasing fever, which continues as long as the 
eruption lasts ; it may be either remittent or continued, sometimes 
terminates with critical symptoms, sometimes gradually. I have 
no extensive experience of the so-called idiopathic erysipelas capitis 
et faciei ; from what I have seen, it seems to me very probable 
that this also starts from slight wounds (excoriations on the head or 
face) or inflammations (nasal catarrh, angina), and is also chiefly of 
toxic origin. 

The treatment of erysipelas is chiefly expectant. We may try 
prophylaxis by carefully cleansing the wound, and thus keeping off 
every thing that can favor the occurrence of erysipelas ; and when 
several cases occur in hospital, we should carefully guard against too 
many of them being in one ward, and occasionally some of the wards 
should be entirely vacated and ventilated for a time, to prevent the 
development of a more intense erysipelas contagion (little as w T e cer- 
tainly know of it). 

As to the local treatment, a series of remedies has been tried to 
prevent the advance of the erysipelatous inflammation and arrest the 
disease at its commencement. For this purpose we circumscribe the 
borders with a stick of moist nitrate of silver or with strong tincture 
of iodine. According to my experience, this does little good, so that 
of late I have entirely left off this treatment. Older physicians 
thought that cold might force the cutaneous inflammation back, and 
thus greatly favor inflammation of the internal organs. Although 
this cannot be regarded as proved, a series of facts renders the use of 
cold apparently unadvisable. We have already mentioned that the 
occasionally great oedema may induce gangrene, which of course would 
be greatly favored by intense cold ; and the application of bladders 
of ice to a large surface, as to the back or the whole face, is scarcely 
practicable ; lastly, the ice does no good, as in spite of it the dis- 
ease runs its typical course, for here almost more than in any other 
inflammation the local process and general infection go hand in 
hand. In the affected skin the patient has a disagreeable tension, 
a slight burning, as well as great sensitiveness to draughts or other 
changes of temperature. Hence it is advisable to cover the diseased 
skin and protect it from the air. This may be done in various ways : 



350 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

the simplest, which I usually employ, is to smear the surface with oil 
and apply wadding ; the patients are generally satisfied with this. 
Others sprinkle the inflamed skin with flour or powder, or scatter 
finely-rubbed camphor in the wadding that is to be applied, thinking 
thus to act specially on the local process. If vesicles form, they should 
be opened with fine needle-punctures, and the loosened epidermis be 
left to dry. If gangrene develop anywhere, moist warmth in the 
form of fomentations or poultices should be applied till the eschar has 
detached and healthy suppuration begun, which is then favored by 
dressings of charpie dipped in chlorine-water. If, after erysipelas, 
abscesses form in the subcutaneous tissue, they should be opened early 
and treated like any suppurating wound. 

Among the internal remedies, we have one which may perhaps 
arrest the development of some cases of the disease. If in strong, 
otherwise healthy persons, in whom the gastric symptoms are very 
prominent, we give an emetic, the advance of the erysipelas is often 
checked. This is not absolutely reliable, but you may try it in suit- 
able cases. Subsequently you employ only the ordinary cooling reme- 
dies. If symptoms of debility show themselves and the disease drag 
on, you should begin with tonics and stimulants ; you may daily give 
a few grains of camphor or quinine, or some wine. 

The inflammations of internal organs occasionally complicating 
erysipelas are to be treated lege artis, and in meningitis you must not 
be afraid to keep a bladder of ice constantly on the head, even if the 
scalp is affected by the erysipelatous inflammation. 

4. Inflammation of the lymphatic vessels {lymphangitis), actual 
inflammation of the lymphatic vessels, occasionally occurs in the ex- 
tremities under various circumstances, which will be mentioned im- 
mediately. The symptoms, in the arm for instance, are as follows : 
There is a wound of the hand ; the whole arm becomes painful, espe- 
cially on motion ; the axillary glands swell and are sensitive, even on 
the slightest touch. If we inspect the arm carefully, we find red striae, 
especially on the flexor side, running longitudinally from the wound 
toward the glands ; these reddened portions of skin are very sensi- 
tive. At the same time there is fever, often a coated tougue, nausea, 
loss of appetite, and general depression. The termination may be in 
one of two directions : under proper care and treatment, there is gen- 
erally resolution of the inflammation ; the striae gradually disappear, 
as do also the swelling and pain of the axillary glands ; the fever 
ceases at the same time. In other cases there is suppuration ; the 
skin of the arm reddens gradually and extensively in a few days and 
becomes cedematous. The swelling of the axillary glands increases, 
the fever becomes greater, and there may even be chills. In a few 



ERYSIPELAS TRAUMATICUM. 35 j 

days fluctuation occurs, most frequently in the axilla, occasionally else- 
where in the arm, the abscess opens spontaneously or is incised, and 
pus, such as is usually contained in a circumscribed abscess, is evacu- 
ated. Then the fever subsides, as do also the pain and swelling; 
and the patient speedily recovers from his disease, which is often very 
painful and troublesome. The termination is not always so favorable ; 
but, in lymphangitis from poisoned wounds, pyaemia is occasionally 
developed, in the subacute form most frequently; of this more here- 
after. In one case with lymphangitis of the leg, where the patient 
had chronic inflammation of the kidneys at the same time, I saw the in- 
guinal glands with the superjacent skin become gangrenous, after they 
had been enormously swollen. This termination is very rare, although 
the pus in these inflammations of the lymphatic vessels, especially 
after poisoning with cadaveric matter, is occasionally putrid in char- 
acter. Acute inflammation of the lymphatic glands ; terminating in 
resolution or suppuration, occurs as an idiopathic disease ; in such 
cases we cannot see the connection, by red lines along the lymphatics, 
between a wound, or another point of inflammation, and the lymphat- 
ic glands ; this may be because only the superficial vessels appear as 
red cords in the skin, while the deeper ones, even when inflamed, are 
not recognizable to the sight or touch. Hence in the patient we only 
know superficial lymphangitis. One of the peculiarities of this dis- 
ease is, that when it occurs in the extremities it rarely extends be- 
yond the axillary or inguinal glands. Once in a case of lymphangitis 
of the arm and adenitis of the axilla I saw pleurisy occur on the 
same side, which possibly may have resulted from extension of the in- 
flammation through the lymphatic vessels. 

We know very little of the pathological anatomy of lymphangitis 
of the subcutaneous tissue, scarcely more than we can see with the 
naked eye on the patient, for this disease is scarcely ever fatal when 
it only attacks the lymphatic vessels, and in animals it can only be 
very imperfectly induced by experiment. The cellular tissue imme- 
diately around the lymphatic vessels is decidedly implicated, the 
capillaries dilated and distended with blood. We cannot decide 
whether the lymphatic vessel is obstructed in the later stages by 
coagulating lymph, or whether coagula form in the lymph at the start 
and irritate the walls of the vessels. If we may transfer the obser- 
vations on uterine lymphangitis, which so often occurs in puerperal 
fever, to the skin, in certain stages there is pure pus in the dilated 
lymphatic vessels; the vicinity of these vessels is infiltrated with 
serum and plastic matter; the plastic infiltration of the cellular tissue 
increases to suppurative infiltration, or even to formation of abscess, 
in which the thin-walled lymphatic vessels themselves disappear ; the 



352 TKAUMATIC AND INFLAMMATORY DISEASES, ETC. 

finer the net-work of lymphatic vessels, the more difficult it is to dis- 
tinguish lymphangitis from inflammation of the cellular tissue. From 
the illustrations of Cruveilhier (Atlas, Livre 13, PI. 2 and 3), we may 
derive an idea of puerperal lymphangitis, and carry this to the same 
affections in other parts. The red stria? that we see in the skin can 
only be caused by dilatation of the blood-vessels around the lymphatics, 
not by blood forcing its way into the latter ; hence in patients we 
really see the symptoms of perilymphangitis induced by contact with 
the poison streaming in the lymphatic vessels. We know the changes 
in the lymphatic glands rather better. In them the vessels are 
much distended, and the whole tissue greatly infiltrated with serum ; 
quantities of cells fill the alveoli tensely, which probably at first im- 
pedes and finally arrests altogether the movement of the lymph in the 
gland ; this blocking up of the gland will to some extent prevent the 
extension of the morbid process. 

Lymphangitis may occur in any wound or point of inflamma- 
tion ; but in my opinion it is always the result of imitation from a 
poison passing through the lymphatic vessels. The nature of this 
poison may vary; it may be decomposed secretion from a wound, 
putrid matters of all sorts (especially that from the cadaver), or 
matters which from excessive irritation form an inflamed point. We 
have already stated that the friction from a boot-nail may excite a 
simple excoriation into a diffuse inflammation, in which a (phlogistic) 
poison may and often does form, and excites lymphangitis ; the same 
thing occurs in points of inflammation from other causes ; by increased 
irritation a material is formed in the inflammatory focus itself, which 
proves very irritant to the lymphatic vessels and their surroundings ; 
even a poison encapsulated in an inflamed part may by increased 
pressure of the blood be driven into the lymphatic vessels, and 
thence into the blood, although without this cause it might have 
remained quiet, and been gradually thrown off or eliminated by sup- 
puration. The following case may serve as an illustration : One of 
my colleagues had a slight inflammation on the finger, from a dis- 
secting wound ; this inflammation was purely local, scarcely observ- 
able ; on a short trip in the Alps he became heated, in the evening 
he had a lymphangitis of the arm and high fever ; the active move- 
ment and consequently increased action of the heart had driven the 
poison, previously lying quiet in the circumscribed point of inflamma- 
tion, through the lymphatic vessels into the blood. Why, in the 
different cases, we have sometimes diffuse phlegmonous inflammation, 
sometimes erysipelas or lymphangitis, cannot be certainly stated, 
though it may be due to purely local causes, and to the character 
of the poison. From our present knowledge of the passage of cells 



PHLEBITIS. 353 

out of the vessels we may imagine that pus-cells developed in the 
wound thence pass into the lymphatic vessels, wander through the 
walls of these vessels, and as bearers of an irritating substance excite 
perilymphangitis, wmile the cells, flowing more rapidly in the centre 
of the vessel, enter the blood, and thus perhaps induce fever before 
the local disease has attained any considerable extent. 

The object of treatment in recent cases of lymphangitis is to ob- 
tain resolution if possible, and to prevent suppuration. The patient 
should keep the affected limb as quiet as possible ; should there be 
gastric derangement, an emetic is very beneficial. The disease not 
unfrequently subsides after the purgation and sweating induced by 
the emetic. Among the local remedies, rubbing the whole limb with 
mercurial ointment is particularly efficacious ; then the arm should 
be covered warmly so as to maintain an elevated, regular tempera- 
ture. For this purpose w T e may employ wadding or moist warmth. 
Should the inflammation increase in spite of this treatment, and dif- 
fuse redness and swelling occur, suppuration will take place at some 
spot. This diffuse inflammation is no longer limited to the lymphatic 
vessels, but the entire subcutaneous tissue participates in it more or 
less. As soon as fluctuation is distinctly perceived, an opening 
should be made, and the pus evacuated. Should healing be retarded, 
it may be hastened by daily warm baths ; these are particularly use- 
ful where there is a great tendency for the disease to return to a 
spot once attacked. A septic poison encapsulated in the lymphatic 
glands, if forced into the circulation by fluxion to the glands, may in- 
duce new lymphangitis and phlegmonous periadenitis ; this explains 
the repeated relapses, and the latency of the disease after infection, 
especially in dissecting wounds. 



LECTURE XXV. 

5. Phlebitis ; Thrombosis ; Embolism. — Causes of Venous Thrombosis ; Various Meta- 
morphoses of the Thrombus. — Embolism. — Eed Infarction, Embolic Metastatic 
4bscesses. — Treatment. 

o. Phlebitis ; T/irombosis ; Embolism ; Embolic Metastatic Ab- 
scesses. — Besides the above forms of inflammation, there is often 
another phlebitis and thrombosis, which, starting from a wound or 
point of inflammation, is at first local, but afterward spreads in a pe- 
culiar manner to several organs. In persons dying from this disease 
we find pus, or friable, purulent, or putrid clots, in the thickened or 
partly-suppurating veins near the injured part. Often, also, there 
23 



354 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

are abscesses in the lungs, more rarely in the liver, spleen, and kidneys. 

Cruveilhier proved that these metastatic abscesses were connected 
with the pus in the veins ; but the mode of this connection was not 
explained till subsequently. 

What I shall tell you to-day on this subject is the result of numer- 
ous investigations and experiments, for which we are indebted to 

Virchow, and which have been so often repeated and confirmed by 
different persons that there can be no doubt of their correctness ; I 
have myself studied the subject a good deal, and shall at the proper 
places state where I have arrived at different results. It would lead me 
too far to follow this great work of Virchow historically, and to give 
you an epitome of it ; I must leave it to your own industry to study 
these works, and content myself with giving you a short resume of the 
positive results. 

The first important question is, What is the relation of the co- 
agulation of the blood to the inflammation of the vessel ? The former 
view, that the coagulation is due to the inflammation of the wall of 
the vessel, is purely hypothetical, and not susceptible of proof. On 
the contrary, we know from the investigations as to the formation 
of thrombus after ligation of arteries, and of the process of healing 
of injured veins, that there is immediate coagulation of blood in the 
injured vessel, before there can be any inflammation of the walls of 
the vessel. The blood-clot forming in veins after their injury, and 
constituting their thrombus, is usually short, it is true, but we may 
readily imagine that it should increase in size from continued de- 
posits of fibrine. You know, from your studies in physiology, that 
we cause coagulation of the fibrine by whipping the blood. During 
the motion of the blood the coagulating fibrine deposits like crystals 
on a rough body, and you can readily satisfy yourselves experiment- 
ally that such a body, as a cotton-thread, introduced into the vein 
of a living animal, soon becomes covered with fibrine. Thus rough- 
nesses of various kinds in the vessels may give rise to more or 
less extensive coagulations of the blood. These roughnesses may cer- 
tainly form on the inner wall of the vein as a result of inflammation, 
and coagulation of the blood may thus be induced. Projections into 
the calibre of the veins may be caused by small abscesses in the 
walls ; formerly, it was supposed that there was a fibrinous coagula- 
tion on the inner surface of the inflamed vein, as on an inflamed 
pleura ; it can scarcely be decided whether this really occurs ; what 
was formerly considered as such has been found to be a discolored pe- 
ripheral layer of the blood- clot. At all events, inflammation of the 
walls of the vessel very rarely causes the coagulation ; much more fre- 
quently the clot forming in a vessel after injury, under certain not accu- 






THROMBOSIS. 355 

rately-known circumstances, forms the starting-point for further coagu- 
lation, and finally for inflammation of the wall of the vessel. Besides 
injuries, there is a second factor from which coagulations may result, 
viz., from retardation of the current of the blood from friction, as in 
contraction of the vessel ; this variety may be called thrombus from 
compression. It also is independent of inflammation of the wall of 
the vein, but may result from inflammation of the perivenous tissue ; 
for in severe inflammation a tissue, especially when it is under the 
pressure of a fascia, may swell so much, partly from serous, partly 
from plastic infiltration, that the vessels will be compressed, and stasis 
and coagulation of the blood be thus induced. These thrombi, from 
compression in very acute inflammation, and especially in acute acci- 
dental inflammation of cellular tissue around wounds, are more frequent 
than primary traumatic thrombi ; it is the most dangerous variety 
of thrombus, as it is most liable to puriform deliquescence. 18 In rapid 
dilatation of a vessel, also, according to physical laws, the current of 
blood is much retarded ; then coagulation takes place at the point of 
dilatation, as we shall hereafter see in aneurisms and varices ; these are 
called thrombi from dilatation. Furthermore, the current of blood 
may be retarded from insufficient contraction of the heart and arte- 
ries ; as this occurs chiefly in persons debilitated by age or severe ex- 
hausting diseases, it is called marasmic thrombus. This, also, is evi- 
dently independent of inflammation of the veins, and occurs most fre- 
quently in parts distant from the heart. 

You must remember that in all these cases the thrombi are at first 
small, and gradually grow from deposit of more fibrine. It has not 
been proved that, in cases where the thrombus attains a considerable 
extent, there is any abnormal increase of fibrine in the blood, although 
this might be supposed. Why traumatic thrombi should extend so 
far in some cases of injuries of the veins, we can only understand in 
cases where extensive ruptures of the veins are caused by extensive 
contusions, and extensive disturbance of the circulation is thus induced. 
But, in cases where a widely-branched thrombus results from a punc- 
tured or incised wound of a vein (as from venesection), it is often 
difficult to explain the cause without resorting to disputed hypotheses. 
Thrombi from injury and compression, and their sequelas, particularly 
claim our attention, while those from dilatation and marasmus we rarely 
meet in surgical cases. It has been observed that venous thrombi 
ending in suppuration are far more frequent in hospitals than in 
private practice, and this tendency to coagulation of the blood has 
been referred to the hospital atmosphere and the miasma it contains. 
That hospital miasm (itself a very indefinite and very variable thing) 
should directly induce coagulation of the blood, can neither be proved 



356 



TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 



nor denied. According to my idea, the connection is probably only 
indirect : toxic-miasmatic infection of a wound, whether induced by 
instruments, dressings, or otherwise, as previously stated, excites acute 
suppurative inflammations around the wound, sometimes as ordinary 
cellular inflammation, sometimes as diifuse lymphangitis, etc. ; thrombi 
from compression are caused by these inflammations, just as happens 
in acute phlegmonous inflammation outside of the hospital ; hence the 
influence of miasmatic poisoning in inducing venous thrombosis is not 
direct, but indirect, acting through the inflammation. 

The next question is, What becomes of the blood coagulated in the 
vessels, and what is its relation to the wall of the vessel ? From the 
injuries of arteries and veins, we are only acquainted with one meta- 
morphosis of the thrombus, namely, its organization to connective 
tissue. In extensive venous thrombi this is a great rarity, and leads 
of course to complete obliteration of the vein. Let us take a very 
simple case, a venesection thrombus. After a bleeding, say from the 
median vein, from an acute inflammation of the cellular tissue there is 
a coagulation of blood in this vein, and also in the cephalic and basilic 
veins, down to the wrist and up to the axilla. From the disturbance 
of the circulation thus caused, there is great oedema of the whole arm ; 
when this subsides, we may distinctly feel the subcutaneous veins as 
hard cords. The course may vary : first, the affection may possibly 
end in resolution — under timely treatment this is usual ; the patient 
should be kept in bed, as he is usually feverish ; the arm should be 
kept absolutely quiet, and covered with a compress thickly coated 
with mercurial ointment. At the same time we give a purgative, and, 
if the tongue be coated, an emetic. Under this treatment, the swell- 
ing of the arm usually decreases, and the fever subsides. Then the 
firm venous cords can be plainly felt ; in six or eight days they become 
softer, and finally cease to be perceptible. We very rarely have the 
chance to examine such cases anatomically in the early stages. Hence, 
we cannot decide to what extent, if at all, the walls of the vein parti- 
cipate in this coagulation of the blood ; but, from the symptoms and 
the examination of the patient, it would appear that the fibrine coagu- 
lated in the vessels is gradually reabsorbed and mingles with the 
blood without injury, like other blood that has been diffusely extra va- 
sated in the tissue. The second termination of inflammation of the 
arm after venesection, complicating thrombosis, is the formation of 
abscess. The first symptoms are those above described ; but then, 
either in the bend of the elbow, the arm, or the forearm, a more 
circumscribed inflammatory tumor forms ; this increases gradually, 
and finally fluctuates distinctly. On incision, pus is evacuated from a 
larger or smaller cavity, the swelling of the arm then gradually de- 



THROMBOSIS. 357 

creases, the abscess heals, and complete cure may result. Anatomical 
examination of these cases shows that there has been suppurative 
inflammation in the connective tissue around the vein. We also find 
that the coats of the thrombosed veins are greatly thickened ; this is 
to be regarded as a result, not as a cause of the thrombosis. I will 
here add that the diagnosis of a venous thrombus cannot always be 
made, from the vein feeling like a hard cord ; for occasionally inflam- 
mation in the cellular tissue around the vein may extend, and cause 
condensation and tube-like thickening of the sheath of the vessel, 
which may readily cause it to be mistaken for thrombus, though it 
does not necessarily lead to it. I have twice seen this mistake of 
periphlebitic cellular induration for thrombus of the saphenous vein, 
and I consider it impossible to make a certain diagnosis in all cases. 
The fact that such a periphlebitis, which is perfectly analogous to 
perilymphangitis, and in which the walls of the veins certainly parti- 
cipate, can exist without thrombosis, proves beyond a doubt that the 
latter is not necessarily the cause of inflammation of the veins, as was 
formerly supposed. Another possible metamorphosis of thrombus is 
friable disintegration. In this, softening of the clot usually begins at 
the point where the thrombus began, that is, at the oldest part. The 
fibrine breaks down into a pulp, which is yellowish or brownish, and 
smeary in proportion to the number of red blood-corpuscles contained 
in the coagulum. This disintegration spreads more and more ; even 
the tunica intima of the vein does not escape, it becomes wrinkled 
and thickened. The thrombus changes to pus, which mingles with 
the detritus of the fibrine, while the walls of the veins and surrounding 
cellular tissue are greatly thickened; occasionally, although rarely, 
small abscesses form in the walls of the vein. Hence, here the inflam 
mation of the wall of the vein is to be regarded as the result of soft- 
ening of the thrombus, and the pus which we then find in the vein 
does not come from the wound (the old idea), but forms in the vein 
from the blood-clot. Often, also, the puriform fluid is only fluid 
fibrinous detritus, while in many cases good thick pus, with fully-de- 
veloped corpuscles, may be found in these veins. If the wound be 
putrid, the fibrinous detritus in the vein may also assume a putrid 
character, putrid fluid being taken up by capillary action of the throm- 
bus from the wound and acting as a ferment on the disintegrated 
fibrine. This capillary action of the thrombus might also be supposed 
to cause an action of the decomposed secretion on the blood. Of course 
there can be no extensive flow of pus or other secretion from the 
wound into the vein, as the opening in the vessel is plugged by the 
thrombus. Should there be a rapid disintegration of the venous throm- 
bus from the peripheral to the central ends, which is rare, there would 



358 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

at once be venous haemorrhage, and the formation of a new thrombus, 
so that even then there could be no entrance of the pus from the 
wound into the vein, or of that from the vein into the blood ; moreover, 
the pus forming and collected in the vein is so shut off by the central 
end of the thrombus, that it cannot mingle with the blood ; at least this 
could only happen if the central end of the thrombus should be entirely 
broken down, but this probably happens very exceptionally, for in 
most cases there are constantly new deposits of fibrine, while disinte- 
gration goes on from the oldest parts of the thrombus. You will thus 
understand that the entrance of pus into the injured vein cannot read- 
ily occur, but that, as will be soon stated, the circumstances must be 
very peculiar to render this possible. I must here briefly interrupt 
the description, to state that Virchow does not distinctly acknowledge 
the transformation of the thrombus to pus ; I have no doubt on this 
point : if the blood-cells in the thrombus have the power of increasing 
and changing to tissue, as seems most probable, there is no reason 
for not referring to them the formation of pus in the thrombus, just as 
we do to the white cells wandering out of the vessels, for the coagu- 
lation of the blood is not firm enough to entirely prevent cell-move- 
ment. That the thrombus may change to true pus by division of the 
white blood-cells does not appear to me disproved ; we have already 
mentioned that this pus, which is usually encapsulated, does not enter 
the circulation, or does so very rarely, and hence has no direct con- 
nection with pyaemia. To resume my experiences of venous thrombi, 
and the history of thrombus, they are to the effect that most venous 
thrombi are the result of very acute inflammation of cellular tissue, 
(especially under fasciae, or tense skin, and in bone), and that the 
coagulum undergoes the same metamorphoses as the inflammatory 
new formation. If the latter lead to formation of tissue, the thrombi 
are also organized to connective tissue ; if the inflammation goes on 
to suppuration or putrefaction, the thrombi also suppurate or putrefy 
and break down. This is the easier to understand, as we know, from 
Von Recklinghausen's and Subnoff^s investigations, that the cells from 
the tissue may pass through the walls of the vein into the thrombus. 
The walls of the vein have the same fate as the thrombus and sur- 
rounding tissue : they are infiltrated with plastic matter, and become 
thicker, or they suppurate. 

Thrombus, with phlebitis, may also run its course as a purely 
local disease, as not unfrequently happens after venesection, and 
in some other cases. Then there can only be further danger when 
the thrombus is friable, or when there is purulent or putrid destruc- 
tion of the coagulum. The central end of the thrombus (as we 
stated when speaking of arterial thrombus) usuallv extends to the 



THROMBOSIS, EMBOLISM. 



359 



Fig. 67. 



point where the next branch joins, and has a conical end, which 
projects a little (Fig. 67, a), and, if the coagulura loses its firmness, 
a portion of the coagulum may be torn off by the current of blood, 
and pass into the circulation ; this passes into the larger veins, thence 
into the right heart, thence to the pulmonary artery, in whose 
branches it is finally arrested at some point of bifurcation, as its size 
does not allow it to pass farther. This branch of the pulmonary 
artery is now closed by a clot of fibrine, as by a cork, a so-called 
embolus / the immediate consequence is a lack of blood in the parts 
of the lung previously supplied by the plugged 
artery. This local lack of blood (ischasmia of 
Virchoio) does not usually last long, but blood 
enters the empty artery from small collateral 
arteries ; it is true, blood may thus again enter 
the vein, but it comes from the small collateral 
branches, and flows very slowly, and may at last 
stop altogether, and coagulation extend back- 
ward through the capillaries even into the throm- 
bosed arterial branch. Thus, as a result of em- 
bolus in the artery, the whole corresponding 
vascular territory is thrombosed ; there may also 
be ruptures of the vessels, haemorrhages ; as the 
arteries of the lungs, spleen, and kidneys, con- 
stantly divide into smaller branches, and thus 
the vascular territory constantly enlarges toward 
the periphery, and resembles a cone with the 
apex in the organ, so the part in which the 
above coagulation occurs must be shaped like a Dia 
wedge or cone. In pathological anatomy these 
coagulations due to embolism have been called 
" red or hemorrhagic wedge-shaped infarctions." 
Frequently as these wedge-shaped infarctions 
occur, they are not a necessary result of embo- 
lism ; for, when the arterial collateral circulation is strong enough 
in the ischemic part to drive the blood through the capillaries, 
as is the case in otherwise healthy persons and in animals, as well 
as in emboli causing little mechanical or chemical irritation of the 
tissue, there is no infarction, at all events no considerable dis- 
turbance of circulation, but we have simply to consider the local 
processes around the embolus, as foreign bodies in the branch 
of the artery. These local processes depend on the character of 
the embolus ; if the latter be a pure fibrinous clot, there is a slight 
thickening of the wall of the vessel at the point where the embolus is 




gram : a, central end of 
a venous thrombus pro- 
jecting into a large 
trunk ; b, a branch with- 
out thrombus ; the blood 
flowing through it may 
detach and carry into the 
circulation the end of 
the thrombus a. 



360 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

located (usually where the artery divides into smaller branches), and 
the latter may have new clots deposited around it, and be organized 
to connective tissue, or be reabsorbed. Should the embolus consist of 
a fibrinous clot impregnated with pus or putrid matter, it excites sup- 
purative or putrefactive inflammation, not only in the wall of the ves- 
sel, but also in the parts around. The metamorphosis of the red infarc- 
tion in part depends on its size, partly on the grade of the circulation 
still continuing in parts of it, and partly on the embolus causing the 
trouble. If the latter be innocuous and the infarction be small, or if 
it be still nourished by some vessels not thrombosed, the coagulum 
forming the infarction may again be dissolved, or else become organ- 
ized to a connective-tissue cicatrix. If the embolus be innocuous, but 
the thrombus extending completely through the whole infarction, the 
tissue and coagulum slowly disintegrate to a yellow, granular, dry 
pulp, which becomes encapsulated, and may calcify ; this is yellow 
dry infarctio?i. If the embolus be impregnated with putrid matter or 
pus, it excites putrid or suppurative inflammation all about it ; the in- 
farction also becomes putrid or purulent, and abscesses form. As we 
were just speaking of the lungs, we may here mention that these ab- 
scesses, which are usually peripheral, often excite pleurisy; that they 
are most frequently multiple in both lungs, and may even induce sup- 
puration of the pulmonary pleura over the abscess, and may thus 
occasionally cause pneumothorax. 

You can hardly imagine, gentlemen, what labor it costs to demon- 
strate this connection between venous thrombi and abscess of the 
lung, so that I can here announce it to you as a simple fact. You 
will read the classical works of Virchow, Panum, 0. Weber, and 
others, on this subject, with astonishment ; it would take too long for 
me to enter into the subject more fully ; we shall here assume the 
right of only taking the facts from these works. "We now understand 
lung infarctions and abscesses ; but how is it with those that occur 
under like circumstances, although much more rarely, in the liver, 
spleen, kidneys, and muscles ; are these also always dependent on 
emboli ? A few years since we could not have answered this ques- 
tion with certainty ; now we may affirm it. From experimental in- 
vestigations, especially those of 0. Weber, it is established that cer- 
tain forms of emboli, especially flocculi of pus, pass the pulmonary 
capillaries without difficult}^, may enter the left heart, and thence the 
systemic circulation, and be arrested in the spleen, liver, kidneys, or 
elsewhere, and cause abscesses. This explains the rare cases where, 
with venous thrombus, there are no abscesses in the lungs, while they 
exist in other organs. If, with abscesses in the lungs, there are em- 
bolic infarctions or abscesses in part supplied by the systemic circula- 
tion, they may be attributed to the formation of venous thrombi 



THROMBOSIS, EMBOLISM. 361 

through the pulmonary abscess ; portions from these thrombi pass into 
the left heart, and thence farther. As regards liver-abscesses, JBusch has 
observed that retrograde movements of the blood from the right heart 
take place in the vena cava, and in this way hepatic emboli may occur. 

The embolic origin of metastatic abscesses is now so undoubted 
that, from the existence of one of these, we decide certainly on a 
venous thrombus undergoing putrid or suppurative liquefaction. The 
discovery of the connection may be easy in some cases, very difficult 
in others : very easy in cases of thrombus of large venous trunks, and 
embolism of branches of the pulmonary artery that may be readily 
reached with the scissors ; very difficult where there is simply coagu- 
lation in some small venous net-work (as in phlegmonous inflammation 
or decubitus) and embolism of capillaries of the lungs, spleen, kidneys, 
liver, muscles, etc. ; still, these latter cases are almost innumerable. 
On favorable objects (as in cerebral capillaries) it has been proved, 
beyond a doubt, that capillary emboli exist in some cases ; it is also 
certain that small veins become thrombosed in all suppurative inflam- 
mations ; it is very difficult, often impossible, to demonstrate this 
anatomically in every case. From what symptoms we conclude 
whether a coagulum is old or recent, will be taught you in the lec- 
tures on pathological anatomy. 19 Here we are only speaking of metas- 
tatic circumscribed inflammations, of infarctions, and abscesses ; these 
alone are connected with venous thrombi and emboli. For diffuse 
metastatic inflammations another explanation must be sought; we 
shall treat of this more under septicaemia and pyaemia. Nor shall we 
here discuss the question of fever in phlebitis and in the formation of 
metastatic abscesses. As phlebitis, with its results, so very often 
comes as an addition to already-existing acute inflammations, it is dif- 
ficult to judge how far it of itself excites fever ; metastatic abscesses, 
like all other points of inflammation, undoubtedly induce fever ; we 
should scarcely expect fever from a simple thrombus of the vessels. 

In dogs, by inducing numerous small emboli in the lungs by in- 
jecting flour or powdered coal into the jugular vein, we may, it is 
true, excite fever, as was shown by JBergmann, Strieker, and Albert; 
but this does not always occur in embolism in other vascular tracts, 
and possibly depends on increased action of the respiratory muscles. 

The treatment of phlebitis and thrombus is the same as that of 
lymphangitis and other similar acute inflammations. Careful frictions 
with mercurial ointment, or, if we fear detachment of the coagulum, 
covering the part with compresses smeared with mercurial ointment, 
or with bladders of ice, and absolute rest of the affected part, are indi- 
cated. Under pyaemia we shall speak of the diagnosis and treatment 
of metastatic abscesses. If phlebitis and thrombosis cause local sup 
puration, the abscesses should be opened as soon as recognized. 



362 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 



LECTURE XXVI. 

IT. — General Accidental Diseases which may accompany "Wounds and Local Inflamma- 
tions. 1. Traumatic and Inflammatory Fever ; 2. Septic Fever and Septicaemia ; 
3. Suppurative Fever and Pyaemia. 

II -GENERAL ACCIDENTAL DISEASES WHICH MAT ACCOMPANY WOUNDS AND 
OTHER LOCAL INFLAMMATIONS. 

The local accidental traumatic diseases which we have so far de- 
scribed are always accompanied by constitutional disease, which is 
chiefly though not always feverish in its nature. Fever is such a com- 
plication of symptoms that it may seem very different according to 
the addition of one or other symptom ; now it is generally determined 
only to say that there is fever when the temperature of the blood is 
elevated, and to measure the intensity of the fever by the height of 
the temperature. I do not think it advisable to combat this position, 
for by abandoning it we should lose the common idea of what we call 
fever, and throw it back into the old chaos. But I must tell you that 
there are many and very dangerous general diseases in patients with 
wounds or other local inflammations, in which no change of tempera- 
ture of the blood can be discovered ; hence the latter is only condi- 
tionally a measure of the patient's danger. Besides the elevation of 
temperature, in fever we have the following chief symptoms : Increased 
rapidity of cardiac action and respiration, loss of appetite, frequently 
nausea, feeling of weakness, great sweating, not unfrequently trem- 
bling of certain groups of muscles (in chills), more or less mental 
excitement and blunting of the senses. Fever is a general disease, 
which may result from many causes ; in other words, the number of 
pyrogenous, like that of phlogogenous substances, is innumerable. 
According to the quantity and quality of these substances (which we 
term poisons) that have entered the blood, one or other set of symp- 
toms is more prominent : thus there is fever with very high tempera- 
ture, while all other symptoms are slight ; fever with great blunting 
of the senses, and but little elevation of bodily temperature ; fever 
whose prominent symptom is severe shivering, so-called chills ; fever 
with disturbance of the gastric functions, fatigue, etc., for the chief 
symptoms. Why, then, should we not have fever (a state of intoxi- 
cation caused by materials absorbed from wounds or points of inflam- 
mation) with all the symptoms, except elevation of the temperature 
of the blood ? From some cause or other this particular symptom 
might in some cases be concealed or prevented from appearing. But, 
as already stated, we shall accept the present view of fever, and only 



TRAUMATIC AND INFLAMMATORY FEVER. 363 

suppose it to exist where we find elevation of temperature of the blood, 
but must then add that there are cases of severe general, accidental 
traumatic and inflammatory diseases which run their course without 
fever. 

But there is another common factor of these general diseases that 
we should bear in mind, viz., that they are all due to reabsorption of 
matters that form in the wounds or the parts around them, or (what is 
about the same thing) in a point of inflammation. On this point we 
agree with the present views, as far as concerns traumatic fever, in- 
flammatory fever, pyaemia, and septicaemia, less so perhaps as regards 
tetanus, delirium potatorum, delirium nervosum, and acute mania. 
But many important reasons favor the view of the latter diseases be- 
ing also of humoral origin ; hence I shall make no further divisions 
among the above diseases. 

1. Traumatic and Inflammatory Fever. — It has been already 
explained (page 92) that the fever appearing in wounded patients is 
partly due to the blood taking up materials resulting from decompo- 
sition of mortified tissue on the substance of the wound, partly to the 
absorption of materials formed by the traumatic or accidental inflam- 
mation ; hence, in the latter case, the nature of the traumatic and 
inflammatory fever is perfectly obscure. On this supposition, which 
we previously tried briefly to prove, it will depend partly on the local 
advantages for reabsorption, partly on the quality and quantity of 
pyrogenous material in question, how great the poisoning will prove. 
There are cases where the vessels opened by the injury close so rap- 
idly, and the whole traumatic inflammation terminates so quickly, that 
there is no general infection or fever at first, and they may not occur 
at all ; such cases are i-re in extensive injuries, they are the ideal 
of the normal course ; in them the plastic infiltration on the edges of 
the wound leads quickly and throughout the wound to solid organized 
new formations, growing firmly in the edges of the wound, and pass- 
ing on to cicatrization immediately or after precedent granulation. 
If we assume this case as a normal type, every traumatic fever is a 
pathological accident. We must acknowledge this in theory, but in 
the great majority of cases, in wounds of any size, fever occurs sooner 
or later ; hence we considered it advisable to treat of traumatic fever in 
the previous description of the general condition of the wounded pa- 
tient. We have still, however, to add something to what was then 
said, which at that time it would have been difficult for you to under- 
stand. Let us first speak of the period at which traumatic fever 
usually appears, and of its course. In many cases, especially where 
the injury has affected tissues previously healthy, the fever does not 
begin till the second day, increases rapidly, and, with evening remis- 



364 



TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 



sions, remains for some days at a certain height, and then ceases 
gradually (rarely within twenty-four hours). According to my very 
numerous observations, in far the greater majority of cases the trau- 
matic fever begins within two days after the injury. This fever is 
usually represented graphically as follows : 

Fig. 68. 





Day of the Disease. 




1. 


2. 


3. 


4. 


£ 


e. 


7. 


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A 


















































A 










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Po\ er-curve after amputation of the ana. Recovery. This and the following fever-curves are 
arranged on the scale of Celsius's thermometer. Each degree is divided into ten parts, 
the horizontal divisions indicate the day of the disease ; the curve is made according to the 
morning and evening measurements ; the two heavy lines indicate the maximum and 
minimum normal temperature of a healthy person. 



The curve shows that, after an amputation of the arm, rendered 
necessary by an injury (measurement was accidentally neglected the 
first day), the fever did not begin till the third day, then continued 
from the fourth to the seventh day ; after the eighth day the patient 
remained free from fever. In other cases, however, secondary fever 
often occurs immediately after amputation. Such an occurrence of 
traumatic fever is quite frequent. I explain it as follows : Immedi- 
ately after the injury the tissue of the edges of the wound was closed 
by infiltration of plastic matter ; the third day this commenced to 
break down into pus, and to mingle with decomposed shreds of tissue 
on the surface of the wound, thus inducing a moderately extensive 
inflammation of the amputation stump, with reabsorption of pus and 
other products of decomposition and inflammation ; this reabsorption 
goes on till checked by some mechanical cause (diminished pressure. 



TRAUMATIC AND INFLAMMATORY FEVER. 



365 



thickening and partial closure of the vessels, etc.). In other cases, 
the fever begins the very day of the injury ; we see this when blood 
has been enclosed between the flaps of the united wound and it has 
rapidly decomposed; frequently, also, when operations have been 
done in tissues infiltrated with the products of chronic infiltration. 
The following case (Fig. 69) may serve as an illustration of this 
second class : 

Fig. 69. 





Day of the Disease, 


1. 2. 


3. 


1, 


5. 


6. 


7. 


8. | 


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— A-i— -7---I 


ns 












\ / ^ 


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37 












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Fever-curve after resection of a carious wrist, with great infiltration of the soft parts. 

Recovery. 

In infiltration of the tissue from chronic inflammation, the finer 
lymphatic capillaries may be contracted and to some extent closed, 
and hence, for some time, may not have carried off sufficient serum 
from the tissue, but the medium-sized lymphatic vessels, like the cor- 
responding veins, which in chronic inflammation have long been ex- 
posed to high pressure, are undoubtedly distended, perhaps even 
gaping, from rigidity of their walls ; hence, if not quickly filled with 
firm plastic infiltration from the start, they take up a good deal of the 
secretion from the wound ; moreover, on the edges of wounds in mor- 
bidly-infiltrated tissue, mortification is particularly apt to occur. This 
explanation of the late and early occurrence of traumatic fever is 
purely hypothetical ; but it is taken from and has been induced by 
numerous observations. It might also be assumed that in one case 



366 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

the ferment absorbed into the blood acted very slowly, in another 
very quickly ; nothing definite can be said on this point. As I for- 
merly believed that the fever was always caused by nervous irritation, 
it was necessary to suppose that this irritability was varied, and hence 
the febrile effect might occur at very different periods, but I have en- 
tirely abandoned this theory, without undervaluing the important 
part played by the nervous system in the origin and symptoms of fever. 

Traumatic fever usually lasts a week ; it is rarely longer, without 
some visible local complication. 

When there is an accidental inflammation of the cellular tissue, 
lymphatic vessels, or veins, about a wound, fever occurs simultaneously 
with this inflammation, or apparently precedes it (coming as an in- 
flammatory secondary fever, either immediately after the traumatic 
fever or when several or even many days have passed without fever). 
I say it apparently precedes, because the first signs of the local affec- 
tion may have escaped us, as they may possibly have presented no 
sensible symptoms, or because the poisonous material may have in- 
fected the blood sooner than it did the parts immediately around ; the 
probability of the latter idea is based on the fact that poison, taken 
into the lymphatic vessels or veins with the lymph or blood, flows more 
rapidly in the centre of the vessel than along its walls, and thus quickly 
reaches the large blood-vessels, while the fluid, moving more slowly 
along the walls of the vessels, only gradually passes into the perivas- 
cular tissue, and there induces inflammation by the phlogogenous poi- 
son it contains ; thus fever (the blood-infection) may appear before 
erysipelas, lymphangitis, or phlebitis (from the local infection), is per- 
ceived. The course of this secondary fever entirely depends on that 
of the local inflammation ; as the latter begins, the temperature rises 
rapidly, often with an initial chill. The longer these secondary fevers 
continue, that is, the longer the poison is kept up, the more danger- 
ous the condition becomes ; rapid emaciation, great sweating, sleep- 
lessness, and continued loss of appetite, are bad symptoms ; usually in 
these secondary fevers there is absorption of pus or infection from 
without. Pronounced erysipelas or inflammation of the lymphatic 
vessels or glands are the relatively most favorable forms of the acci- 
dental inflammations, as sooner or later they generally lead to a certain 
usually favorable termination, and thus are somewhat typical in their 
course, although the duration of an erysipelas may vary from three 
days to three weeks or more, and prove very debilitating ; at first the 
fever-curve rises rapidly, then remains for a time at a certain height, 
usually with morning remissions ; not unfrequently the temperature 
falls rapidly ; the same is true of lymphangitis. Fortunately, it is rare 
for lymphangitis and erysipelas to extend deep into the cellular tis- 
sue and under the fasciae ; in such a case the disease would be classed 



TRAUMATIC AND INFLAMMATORY FEVER. 



367 



among the severer inflammations, and would lose its somewhat typical 
character. 

In diffuse, deep inflammation of the cellular tissue, with or without 
venous thrombosis, the fever does not begin so suddenly, but, from the 
first, always has a decidedly remittent type, and, like the local affec- 
tions, is incomputable in its further course ; the loss of strength, the 

Fig. 70. 



Day of the Disease* 



1. 



2. 



3. 



x 



10. 



3%5 



S 



39 




38J 



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Fever-curves in erysipelas traumaticnm ambulans faciei, capitis et colli, following extirpation 
of a cancer of the lip. Recovery. 



emaciation, sweating, sensitiveness, and excitability of the patient, 
attain the highest grade. Intermittent fever and metastatic inflam- 
mations, the chief symptoms of those malignant traumatic fevers 
which we call " pyaemia," are greatly to be feared in such cases. 

In all these fevers the quantity of urea is increased and exceeds 
the amount of nitrogenous food consumed ; at the same time, accord- 
ing to recent investigations, the weight of the body diminishes con- 
siderably. 

As long as the constitutional symptoms, especially those due to 
the fever, do not extend beyond the above, and especially if the dis- 
ease does not prove fatal, we are generally satisfied with the terms 
" traumatic, suppurative, or secondary fever." But, if other symptoms 
occur, and death results, these severer infections have two other 
names, " septicaemia " and " pyemia." We follow this common classi- 
fication. 



368 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

2. Septic Fever (Septicaemia). — By septicaemia, we understand a 
constitutional, generally acute disease, which is due to the absorption 
of various putrid substances into the blood, and it is thought that 
these act as ferments in the blgod, and spoil it so that it cannot fulfil 
its physiological functions. This disease may be induced in ani- 
mals by injecting putrid matter into their blood or subcutaneous tis- 
sue, and it has been found that large animals (large dogs, horses, etc.) 
may, under certain circumstances, live through the putrefactive blood- 
poisoning, although it makes them very sick. Certain circumstances 
are necessary for putrid matter to be taken into the blood of man ; 
such substances are only taken through the healthy skin and mucous 
membranes when the putrid substances have a destructive or cauter- 
ant action, or an active power of penetrating, like fungi and infusoria. 
Diseased skin or wound surfaces take up such putrid matters more 
readily, but even they only do so under certain circumstances ; for 
instance, they do not readily pass through well-organized, uninjured 
granulations. If we dress a nicely-granulating wound on a dog with 
charpie dipped in the filthiest putrid matter, if the latter contain no 
cauterant substance that may destroy the granulation surface, the ani- 
mal will not sicken, nothing will be absorbed. Hence I conclude that 
the poison must in some way be prevented from entering the blood- 
vessels in the surface of the granulations. If the septic poison be in- 
troduced into the fresh tissue, it not only excites severe local inflam- 
mation, but quickly induces general fever. From these peculiar con- 
ditions under which infection from putrid substances usually takes 
place, it seems to me evident that the poison is absorbed chiefly by 
the lymphatic vessels, as I have already mentioned. Remember, also, 
that, in contused wounds, decomposing shreds of firm connective tis- 
sue, especially of tendons and fasciss, often lie for a long time on 
granulating wounds, without any septic poison passing from them 
through the superficial vessels of the granulations into the blood ; this 
observation verifies the experiments made on dogs. But, if the poison 
be not taken up by the blood-vessels, or be taken only under certain 
circumstances, it is very probable that its absorption is chiefly through 
the lymphatic vessels. I will not deny that possibly in certain swol- 
len states of the walls of the blood-vessels, as well as from capillary 
attraction, and also through the thrombi of the vessels, infectious mate- 
rials may reach the blood, nor that cells take up septic molecular 
substances and may wander with them into the blood-vessels ; but, on 
the whole, I consider this mode of infection the exception, especially 
if the infectious substance be not dissolved, but exist as very fine 
molecules ; if, for instance, it be taken up in the form of dust. Of the 
healthy parts of the body exposed to the air, it has only been proved 



SEPTICEMIA. 369 

that dust-like bodies (as coal-dust) enter the lungs, and may thence 
reach the bronchial glands (thence also the blood), while a similar 
absorption from the walls of the intestines has not yet been observed 
or experimentally proved. Should the miasmata really be small fungi, 
that is, molecular bodies, from what has been said, it would seem very 
probable that the infection may take place through the respiration ; if 
this should be proved, it might be of great practical consequence. 

Of late, many attempts have been made to determine what sub- 
stance in decomposing animal tissue is the true poisonous principle, 
and for this purpose putrid fluids have been treated chemically till 
some one body should be found which in the smallest dose should ex- 
cite the symptoms of septic poisoning. Thus JBergmann has produced 
a body of this nature from decomposing yeast, which he calls sepsin. 
To prove that this body alone, (whose presence Fischer could not 
prove in decomposing serum or pus) is the poison, it would be neces- 
sary to prove the innocuousness of all other bodies chemically formed 
during putrefaction. But this cannot be done ; sulphuretted hydro- 
gen, sulphuret of ammonium, butyric acid, leucin, and some other sub- 
stances, forming during the putrefaction of organic bodies, also act as 
septic poisons when injected into the blood ; so that I cannot enter 
into the laborious search for one body in the putrid fluids which 
shall bear all the blame of the injurious effects. It is very probable 
that in decomposing fluids, according to their qualities, degree of 
concentration, temperature, etc., very many different poisonous sub- 
stances may form, which I further imagine as going on changing till 
they reach some final terminal stage. 

Whether this terminal stage is always the same is still to be de- 
termined. This is not the place to discuss such difficult questions 
exhaustively ; so far as my experience, observations, and studies go, 
I consider it at least probable that the septic matters are formed in 
the inflamed and gangrenous tissues, and pass to the blood as a de-* 
veloped poison. Opposed to this view is another, that only a fer- 
ment goes to the blood from the tissues (ultimately from the air), 
which soon causes fermentation or decomposition (O.Weber). Ac- 
cording to this, the absorbed septic matters would not be in them- 
selves poisonous, but would develop poison in the blood from its 
components. 

Of late this hypothesis is rendered more precise by asserting that 
the ferment is coccus or bacteria (monads of Hiceter). I cannot 
agree to this, for I have never found micrococcus in the blood of pa- 
tients who afterward died of septicaemia, or who had already died of 
it. I must add that some time after the injection I could not find 
these organisms in the blood of dogs into which I had injected putrid 
24 



370 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

fluids with coccus and bacteria, and which died of septic poisoning ; 
nor could I find them some hours after death. Hence, it seems as if 
coccus and bacteria not only could not grow in living blood, but 
soon disappeared from it. According to these observations, it is not 
justifiable to suppose that septicaemia is a haematozymotic process 
due to organisms, which, from analogy with fermentation, must be 
based on an enormous vegetative energy of the vegetable ferment. 
Numerous investigations on these highly interesting scientific ques- 
tions have failed to give a full explanation. From the works of A. 
Hlller and E. Anders, it seems certain that the putrid poison ad- 
heres not only to the microscopic organisms, but is found also dis- 
solved in the poisonous fluids, although not so constantly. Particu- 
larly interesting are the experiments of A. Hiller, in which the blood 
of a rabbit which was killed by putrid fluid free from bacteria killed 
another rabbit into which it was injected, and increased in poison- 
ous effect with each succeeding injection. According to previous 
views, this could only be explained by the presence of a constantly 
renewing and increasing inanimate ferment. When Davaine first 
published the same experiments made with fluids containing bac- 
teria, and they were confirmed by Strieker, it was considered almost 
certain that the results were only explicable by a living ferment; 
now this view is rendered less imperative by the above experiments 
of Hiller. At all events, in future investigations more attention 
must be directed to distinguishing " septogenous ferment " from 
" septic poison," the final product of fermentation ; this may cost 
much labor. It is very possible that in some animals the septoge- 
nous ferment may at the same time be a septic poison. 

After these general observations, we shall consider those surgical 
cases that give rise to septic infection. First come the cases where 
there is decomposition on recent wounds ; it usually appears within 
the first three days whether in such cases there will be intense, un- 
usual, loeal, and general infection. If the local infection merely evince 
itself in moderate inflammation, which soon leads to circumscribed 
suppuration, if the general infection be followed by moderate fever, 
the affection would come under the head of traumatic fever. But if 
the local infection be very extensive, with phlegmonous inflammation 
and putrefaction, and the general condition assume a character soon 
to be described, we call the state septicaemia. In other cases the re- 
absorption of putrid matter takes place from a traumatic or idiopathic 
extensive gangrenous spot (as from gangrene due to disease of the 
arteries) ; this is more frequently the case in moist than in dry gan- 
grene. In the same way the requirements for the reabsorption of 
putrid substances exist, if after delivery the placental surface of the 



SEPTICEMIA. 



371 



uterus becomes gangrenous ; some of the cases of puerperal fever are 
septicaemia. 

It will be evident to you that the term septicaemia essentially de 
pends on the etiology, just like the group of "typhous" diseases; 
and that mild septic-traumatic fever has the same relation to septi- 
caemia that typhus febricula has to typhus ; in fact, the name " septic 
febricula" has been proposed. Still, as typhus in its different forms 
is characterized by its symptomatology and pathological anatomy, this 
is also the case in septicaemia, although in it the pathologico-anatomical 
appearances are slight. Now, what characterizes the course of septi- 
caemia ? The nervous symptoms deserve the first mention : the patients 
are apathetic and sleepy, if not entirely comatose ; rarely there is fear- 
ful excitement, and occasionally maniacal delirium ; at the same time 
the subjective feelings are good; the patients do not suffer much. The 
tongue is dry, often as hard as wood, which renders the speech very 

Fig. 71. 



ij 


Day of the Disease, 


1 


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2. 


3. 


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8. 


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Fc-ver cur,e iD eefrioimia af&rr extirpation of an immense lipoma, from between the muscles 

of tho thigh. Death. 



peculiar; the patients are thirsty, but rarely drink, on account of their 
ivreat apathy. Not always, but very frequently, there is profuse diar- 
rnnea, more rarely vomiting. At first there may be great sweating, 



372 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

later the skin is dry and flabby. The urine is scanty, very concen- 
trated, and occasionally albuminous. As the disease progresses, the 
patient passes his urine and faeces in bed. Bed-sores over the sacrum 
occur early. The fever (as shown by the bodily temperature) at first 
rises high ; in acute pure septicaemia intercurrent chills never occur 
in the course of the disease, and initial chills are very rare. In the 
prognosis of septicaemia the conditions of the pulse and tongue are 
more important than the temperature, A small frequent pulse 
and dry tongue are bad signs ; while a normal temperature has no 
prognostic value, very high or very low temperature makes the 
prognosis worse. 

This is the usual course of acute pure septicaemia from recent in- 
juries ; but the patient may die in the first stages, with rising tempera- 
ture. Cases also occur where the onset of the fever is scarcely marked 
by an elevation of temperature, and lastly some cases run their course 
without fever or with abnormally low temperature; the latter occurs 
especially in old persons with spontaneous gangrene ; but the other 
symptoms above mentioned usually exist. From this and particularly 
from the above curve, we see that failing of the temperature of itself 
is by no means a sign of improvement, but that the other constitutional 
symptoms (strength, mental state, tongue, pulse, etc.) must also be 
taken into consideration. 20 

I hope that, from what has been said, you have formed a true idea 
of septicaemia. Where the symptoms of the disease are marked, the 
prognosis is very bad ; we shall speak of the treatment at the end of 
this section. 

We now come to the post-mortem appearances. Occasionally it 
is difficult for us to recognize on the cadaver the ©edematous infiltration 
and brownish discoloration of the skin that we observed about the 
wound during life. In other cases that had a long course (six to eight 
days) we find the subcutaneous tissue infiltrated with bloody, serous 
fluid ; wiiere the course is still longer (two weeks or more) the disease 
shows itself mostly by extensive suppuration of the cellular tissue, 
vith more or less extensive gangrene of the skin. Frequently the in- 
ternal organs present no morbid appearances. If there was continued 
profuse diarrhoea during life, you find swelling of the solitary and 
conglobate intestinal follicles. The spleen is often enlarged and 
softened, rarely it is of a normal size and firmness ; the liver is usually 
full of blood, relaxed, and very friable, but without further change. 
In the heart the blood is lumpy, half-clotted, tarry, and rarely firmly 
coagulated, buffy ; in most cases the lungs are normal. Sometimes 
we find diffuse single or double pleurisy of moderate extent, and also 
traces of pericarditis. Under pyaemia w r e shall speak more fully of 
these diffuse metastatic inflammations wdiich are not due to emboli 



PYAEMIA. 373 

here it is not very necessary to do so any more than it is to treat of 
embolic infarctions and putrid abscesses, which are exceptionally 
found in septicaemia when the patients resist the disease a long time, 
and venous thrombi have occurred about the wound or gangrenous spot. 
As nothing special has been found on chemical analysis of the blood 
from the bodies of such cases, it must be acknowledged that what we 
find postmortem adds little that is characteristic to the picture of the 
disease, which is essentially etiologico-symptomatological ; if we have 
not seen the patient during life, we shall often examine the dead body 
in vain for some palpable cause of death. 21 

3. Suppurative Fever, Pyozmia. — Pyaemia (the name was formed by 
Piorry from ttvov, pus, and alfia, blood) is a disease which we suppose 
to be due to the absorption of pus or its constituents into the blood; 
it holds the same relation to simple inflammatory and suppurative 
fever that septicaemia does to simple primary traumatic fever; it is 
symptom atologically characterized by intermittent attacks of fever, and 
in its pathological anatomy by the frequency of metastatic abscesses 
and metastatic diffuse inflammations. Other names for this disease are : 
metastatic suppurative dyscrasia, pus disease, purulent diathesis. 

To give you at once an approximate picture of this disease, I will 
describe for you a case of pyaemia. 

A wounded patient enters the hospital with a compound fracture 
of the leg just above the ankle. The injury has resulted from the 
fall of a heavy body. You examine the wound, find an oblique frac- 
ture of the tibia, but consider the injury of such a nature that it may 
heal. So you apply a dressing ; at first the patient feels very well ; 
he has but little fever till about the third or fourth day, then the 
wound becomes more inflamed, secretes relatively little pus, the sur- 
rounding skin becomes cedematous and red, the patient grows very 
feverish, especially toward evening, the swelling about the wound in- 
creases and slowly spreads, the whole leg grows swollen and red, the 
ankle-joint very painful ; on pressure over the leg, a thin, bad-smell- 
ing pus flows slowly from the wound ; the swelling remains limited to 
the leg ; there is no trouble of the mind, no sign of intense, acute 
septicaemia ; the patient is exceedingly sensitive to every dressing, he 
is restless and discouraged ; there is febris continua remittens, with 
high evening temperature, and frequent, full, tense pulse ; the appe- 
tite is lost, and the tongue heavily coated. This would be about the 
twelfth day after the injury. Quantities of pus flow from different 
parts of the wound; somewhat above it fluctuation is distinct; this 
collection of pus may be evacuated through the wound by careful press- 
ure, but the escape is greatly impeded, and an incision must be made 
at the above point. This being done, a moderate quantity of pus is 



374 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

evacuated ; a few hours later the patient has a severe chill, then dry 
burning heat, and, lastly, profuse sweating. The appearance of the 
wound improves somewhat ; but this does not last long ; we soon no- 
tice a new abscess near the wound, but rather behind it in the calf ; 
there is another chill ; more counter-openings are required at different 
spots to give exit to the pus, which forms in quantities. The left leg 
is the injured one ; some morning the patient complains of great pain 
in the right knee-joint, which is somewhat swollen, and is painful on 
every motion. The nights are sleepless, the patient eats very little, 
drinks a great deal, and becomes much debilitated; he emaciates, 
especially in the face, the color of the skin changes to yellowish, the 
chills recur ; the patient then begins to complain of pressure on the 
chest ; he coughs some, but raises little sputum ; on examining the 
chest, you find a moderate pleuritic exudation on one or both sides, 
from which, however, the patient does not suffer much, but he com- 
plains more of the right knee, which is now much swollen, and con- 
tains a great deal of fluid ; as the patient sweats a great deal, the 
urine becomes very concentrated, and is occasionally albuminous. 
Finally, there is decubitus, but the patient does not complain much 
of this ; he lies quietly, half insensible, muttering to himself. This 
would be about the twentieth day after the injury ; the wound is dry, 
the patient looks miserable ; the face, and especially the neck, is ema- 
ciated, the skin is very jaundiced, the eyes dull, the trembling tongue 
is perfectly dry, the skin cool, the temperature low, and only elevated 
at evening, the pulse small and frequent, the respirations slow, the 
breath of a peculiar cadaveric odor ; the patient becomes entirely un- 
conscious, and may, perhaps, remain so for twenty-four hours before 
death. On aittopsy, you find nothing pathological in the skull ; 
heart and pericardium normal ; in the right auricle and ventricle a 
firmly-coagulated, white, fibrinous clot ; both pleural cavities are filled 
with a cloudy, serous fluid ; the surfaces of the lungs are covered with 
a net-like layer of jaundiced fibrine ; on tearing this off, under it, in the 
substance of the lung, but particularly on its surface, you find quite 
firm nodules, as large as a bean or chestnut. These are found chiefly 
in the lower lobes ; sections through them show that they are mostly 
abscesses. The parenchyma of the lungs, somewhat condensed, forms 
the capsule of a cavity, which is filled with pus and disintegrated 
lung-tissue ; others of these nodules are bloody red, and, on section, 
the cut surface is somewhat granular, and in their midst there are oc- 
casional spots of pus of various size, and it is evident that they 
change to abscesses. They are the red infarctions, terminating in 
abscesses, with which you are already acquainted. Some of these 
abscesses lie so near the surface that they implicate the pleura, and 



PYEMIA. 375 

the pleuritis is secondary. The liver is quite vascular and friable, but 
is otherwise apparently normal. The spleen is somewhat enlarged, 
and, on section, shows a few firm, wedge-shaped nodules, with their 
points inward, and their broad outer ends along the surface ; they re- 
semble the red infarctions of the lungs, and within they also have 
partly broken down into pus. The intestines, urinary and genital 
organs, show nothing abnormal. An incision into the right knee, 
which was painful during life, evacuates a quantity of flocculent pus ; 
the synovial membrane is swollen, and in part hemorrhagic, injected ; 
the lustre of the articular cartilage is dulled. Examination of the 
wound shows little more than we found on the living patient ; that is, 
extensive suppuration of the deep and subcutaneous cellular tissue, as 
well as pus in the ankle-joint ; the walls of all these collections of pus 
consist mostly of broken-down tissue, true granulation has only oc- 
curred at a few points. The fracture is, however, more complicated 
than had been supposed, for a longitudinal fissure reaches to the 
ankle-joint, and on the posterior aspect of the tibia, which we could 
not examine during life, there are several detached fragments of bone. 
In the veins of the leg there are old plugs of fibrine here and there, 
also yellow puriform detritus, and in some places pure pus. 

Let us make some reflections on this case, and suppose that you 
have seen a series of such cases, so that you are convinced that it is 
not an accidental association of various diseases, but a regular com- 
bination. You have an extensive, steadily-increasing suppuration in 
an extremity, with intense continued fever, which has exacerbations. 
To this are added suppuration in some distant joint, and circumscribed 
inflammations, ending in formation of abscesses in the lungs and other 
organs. These multiple points of inflammation keep up the fever, 
and they disturb the functions of the affected organs, and the patient 
dies of exhaustion. The peculiar and essential feature, as you will 
readily see, is the appearance of various points of inflammation, after 
the primary suppuration has attained a certain grade. You know the 
explanation of the occurrence of metastatic abscesses : they are al- 
ways caused by venous thrombosis and embolism ; it is unnecessary 
to recur to this. It is more difficult to explain the diffuse metastatic 
inflammations which occur both in septicaemia and pyaemia ; they by no 
mesjis always depend on abscesses of the lungs, as does pleurisy in 
the cases above mentioned ; there are metastatic diffuse abscesses of 
the eye, cerebral membranes, subcutaneous tissue, joints, periosteum, 
liver, spleen, kidneys, pleura, pericardium, etc., which are independent 
of abscesses or emboli. The occurrence of these metastases cannot 
always be exactly explained. If the metastatic disease be nearly 
united to the original abscess, it might be attributed to conduction 



376 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

of the inflammation from the latter, possibly through the lymphatic 
vessels ; as in cases where, after amputation of the breast or exar- 
ticulation of the humerus, there is pleurisy of the same side, or a 
fracture of the lower third of the leg is accompanied by suppuration 
of the knee-joint. In other cases it is possible that a part already 
diseased, or predisposed to inflammation, becomes acutely affected, as 
a result of the general febrile disturbance ; for instance, sometimes 
fracture callus, say of the radius, that is already tolerably firm, sup- 
purates in the third or fourth week, if the patient becomes pyemic 
from a complicated fracture of the leg, or from a bed-sore. Bat there are 
many cases where, as above stated, such explanations prove insufficient. 
Then we try to satisfy ourselves that there was a predisposition to in- 
flammations, especially to suppuration in certain organs, which is 
necessarily accompanied by pus-poisoning ; that the pus-poison circu- 
lating in the blood has a specific phlogogenous action on certain organs. 
I can give you no farther explanation on this point, but would like to 
render this hypothesis a little more plausible to you, by comparing it 
with analogous observations on the specific phlogogenous action of 
certain drugs, of which we have already spoken when treating of the 
etiology of inflammation, and its toxic-miasmatic causes, and their 
mode of action (page 268). Diffuse metastatic inflammations of in- 
ternal organs are rare,- unless among them we include the diffuse en- 
largement of the spleen, which is frequent, if not constant, in pyaemia. 
The diagnosis of metastatic abscesses and inflammations is easy, where 
the}' lie at the surface of the body and extremities ; metastatic me- 
ningitis or choroiditis is relatively easy to recognize. The diagnosis 
of metastases to the lung may prove difficult ; the foci are often so 
small and so scattered in the lung that they cannot be detected by 
percussion; the accidental pleuritic effusion often aids in the diagnosis 
of metastatic pulmonary abscesses ; if there are bloody sputa and 
severe bronchial catarrh, the diagnosis may be considered certain ; the 
subjective symptoms are often very slight ; the dyspnoea is only severe 
when there is extensive pleuritic effusion. In pyaemia there is often 
more or less jaundice. It is not yet fully determined whether, in these 
C3 ses, the coloring matter of the bile is formed from the red coloring 
matter of the blood without the intervention of the liver, or if icterus 
ever can occur without the liver having something to do with it, al- 
though most observers regard it as always being hepatogenous. At 
all events, icterus in pysemia does not admit a diagnosis of abscess of 
the liver ; this may be suspected if there be great pain in the hepatic 
region, but, instead of the expected hepatic abscess, I have, in such 
cases, occasionally found acute diffuse softening of the liver, which 
was accompanied by almost bronze-like icterus. Enlargement of the 



PYAEMIA. 377 

spleen may sometimes be diagnosed by percussion. Occasionally, 
albumen, with epithelial and gelatinous casts and blood in the urine, 
especially if there be considerable coincident decrease in the amount 
of urine excreted, justifies a diagnosis of acute metastatic nephritis ; 
but during life it cannot be certainly determined whether the 
kidney has numerous metastatic abscesses or is diffusely inflamed, 
as may also occur metastatically. Pulmonary and splenic abscesses, 
as well as articular inflammations, are the most frequent, while those 
of the liver, kidneys, and other parts above mentioned, are far more 
rare. 

There is one symptom of pyemia that we must study more care- 
fully, viz., chills. They occur irregularly, rarely at night, although 
they may come at any time of day, and their duration and intensity 
vary exceedingly ; sometimes the patient only complains of slight 
cnilliness and temporary shivering, sometimes he trembles and chat- 
ters his teeth as hard as in " chills and fever." At first the chills come 
rarely, then more frequently, two or three times daily ; toward the 
end they again abate. The attacks themselves resemble those of 
intermittent fever in regard to chill, dry heat, and sweating ; but after 
the attack there is no complete cessation of the fever, it almost al- 
ways continues to some extent. Now, what is the true nature of this 
chill ? When we have opportunity to make observations on ourselves 
we find that there is a spasmodic contraction in the skin ; we must 
spasmodically knock the teeth together, even against our will ; if this 
ceases for a moment, we do not feel cold, but rather hot, and the 
feeling of chilliness is more in the imagination, for otherwise we only 
have similar sensations and spasmodic trembling as an effect of great 
cold. During the chill the limbs and skin feel cold, as the blood has 
been driven from the capillaries by the spasm of the cutaneous mus- 
cles. But if you measure the bodily temperature with the thermom- 
eter from the commencement of the chill, you find that the tempera- 
ture rises constantly and rapidly, occasionally from 3° to 5° Fahr., in 
a quarter or half an hour. At the end of the chill, and during the 
period of dry heat, the bodily temperature usually attains its highest 
point ; it may reach 108° Fahr., but rarely goes over 104.5° Fahr. ; 
from this point it gradually declines. The rapid increase of temper- 
ature is always in proportion to the phenomena of the chill ; a cer- 
tain irritability of the nervous system also appears necessary for its 
occurrence, for in torpid or narcotized persons chills are much more 
rare than in very irritable subjects (see page 171). 

The most varied acute diseases begin with chills and fever, espe- 
cially the acute exanthemata, pneumonia, lymphangitis, etc. ; more 
rarely the acute miasmatic infectious diseases, such as typhus, plague, 



378 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

and cholera. Usually, however, these chills are not repeated, but 
only the onset of the disease is accompanied by this symptom ; it 
seems as if the first entrance of certain pyrogenous substances into 
the blood of persons otherwise healthy was especially apt to induce 
chills, or as if certain infectious materials entering the blood excited 
particularly intense fever with chills. Hence, although we cannot 
consider chills a characteristic of pyasmia, still their frequent recur- 
rence, as well as the generally intermittent type of the fever, is pecu- 
liar to this disease. Intermittent fever is the only disease in which 
we see any thing similar ; there we have intermittent attacks of fever 
with regular intervals ; we do not koow on what this interval depends, 
but I should consider the immediate cause of the attacks of fever to 
be paroxysmal pouring out of morbid products from the spleen ; in 
melanasniia and pigment metastases we have anatomical evidence 
that in intermittent fever substances pass from the spleen into the 
blood ; it is known that collections of normal secretion occur in the 
pancreas and spleen, and are poured out during digestion ; hence, it 
does not seem to me too bold to assume that, with these physiological 
evacuations of certain substances from the spleen, pathological prod- 
ucts may also enter the blood. Thus, in pyaemia, from time to time 
pus or its constituents might be poured into the blood, and under 
otherwise favorable circumstances fever and chills might be induced. 
Extensive progressive inflammation about the wound must be re- 
garded as the chief source of such repeated purulent infection ; 
destruction of the granulating surface by frequent injury, rapid de- 
struction of the granulations by chemical agents, any new progressive 
inflammations occurring about the wound, may open an entrance for 
the pus into the lymphatic vessels which have been closed ; new in- 
flammation may cause suppuration of the coagula in the lymphatic 
vessels, and the pus from these may enter the blood ; it might also 
be imagined, although difficult to prove, that in venous thrombosis the 
central coagula enclosing the pus in the veins are torn loose, and the 
pus is swept into the blood through a passable collateral vein, which 
opens farther on ; this might be caused by muscular contractions. 
Lastly, metastatic inflammations, whether due to emboli or not, also 
induce new attacks of fever ; but that this is not the only cause is 
proved by occasional autopsies on cases that have died from intermit- 
tent purulent fever, after ten or twelve chills, where no metastatic 
inflammations have been found; the cause of the repeated chills may 
then lie in the mode of extension of the local process, or be hidden 
in the bones or elsewhere. Statistics greatly favor the idea that 
the chills depend on new inflammations, for they show that the chills 
(or at least the intermittent fever attacks, which may occur without 



PYAEMIA. 379 

chills) occur far more frequently in persons in whom subsequent 
autopsy shows inflammation of internal organs than in those where 
this is not the case. It must be mentioned, as a matter of observa- 
tion, that chills occur almost exclusively in the commencement of 
acute inflammations, and are intermittent only in intermittent fever 
and reabsorption of pus, while they do not occur in acute septicaemia. 
Probably the chemical qualities of the infecting matter here play an 
important but unknown role. Unfortunately, experiment here leaves 
us entirely in the dark ; I have never succeeded in exciting chills or 
intermittent attacks in rabbits, dogs, or horses, by injections of putrid 
substances or good pus ; pus and putrid matter have the same ac- 
tion on animals, as regards fever ; we can only artificially excite the 
intermittent course of the fever in animals by repeating the injec- 
tions. 

From what you have just heard, you will understand that the usual 
method of measuring temperature morning and evening can give 
no picture of the course of the fever in pyaemia ; for in this way the 
measurement may fall at one time in the acme, again in the deferves- 
cence of an attack of fever, or at another time in the remission (com- 
plete intermission of the fever rarely happens in pyaemia) ; thus we 
would of course have very irregular fever-curves. To obtain an ac- 
curate picture of pj^aemic fever, it would be necessary to leave the 
thermometer constantly in position, and to note the temperature 
every hour or so ; as this would greatly annoy the patient, and we 
have enough other signs to decide the prognosis and treatment, I 
have been unable to make up my mind to do this. The investiga- 
tions as to whether pyemic pus contains peculiar substances, or its 
qualitative composition differs from that of the pus in persons who 
recover without any complications, have thus far proved without re- 
sult. The pus of pyaemic patients does not always smell bad, nor 
always contain cocci ; still cases where putrid pus containing- cocci 
enters the circulation are the more frequent. We do not know 
whether the pus coccus grows after entering the blood. I have not 
found cocci and bacteria in the blood of pyaemic patients. 

The mode of onset of pyaemia varies in some respects. Most fre- 
quently this disease, which we regard as a peculiar, malignant form 
of suppurative fever, begins when suppuration begins, or later, when 
new inflammations occur about the wound, whether they be imme- 
diately connected with the traumatic inflammation, or occur acciden- 
tally after the point of traumatic inflammation has been bounded. 
Then the pyaemic fever develops from the traumatic fever, or from the 
secondary fever, and in such cases these are considered by some ob- 
servers as prodromal stages of pyaemia. The moment when the pa- 



380 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

tient becomes pyemic cannot be decided any more accurately than 
can the passage of primary traumatic fever into septicaemia. I retain 
the designation " pyaemia " for the disease just described. I have told 
you that the reabsorption of pus is the cause ; intermittent course of the 
fever, with rapidly-increasing marasmus, the chief symptom ; and the 
metastatic inflammations very essential anatomical conditions ; but it 
is sometimes very difficult to decide whether a given case shall be 
termed severe traumatic fever, septicaemia ; or severe suppurative 
fever, pyaemia. The chills may not occur ; then it is difficult to de- 
termine the intermittent course of the fever ; the metastases may not 
be diagnosticated during life. If you have a case of osteomyelitis 
with frequent chills, if the patient dies and you find no metastases, is 
that pyaemia ? Or an old marasmic man has a compound fracture ; he 
dies with symptoms of complete exhaustion in the fourth week, with- 
out having had very high fever or chills ; you find no metastases ; is 
that pyaemia ? For the beginner who would like to have every thing 
well systematized, these questions, and their doubtful answers, are 
very embarrassing. You will find surgeons who call the above cases 
pyaemia, others who term them simply intense suppurative fever or 
febrile marasmus. If you adhere to the above description, and have 
correctly comprehended the relation of infection to venous throm- 
bosis and embolism, it is to be hoped you will not be perplexed about 
the names. Indeed, it is scarcely possible to make a name for every 
link between septicaemia, purulent infection, diffuse metastatic inflam- 
mations, thrombosis, embolism, etc. For instance, septicaemia occurs 
without a trace of metastases, with diffuse metastases, with throm- 
bosis and embolism ; purulent infection without a trace of metastases, 
with diffuse metastases and thrombi, with thrombi alone, with thrombi 
and emboli ; there are thrombi with local sequences without emboli, 
with emboli, with haemorrhagic effusions, with apoplexies, etc. Be- 
sides the words already given, some others have been introduced to 
designate combinations of the various processes. For pure purulent 
infection (infection with thin, bad pus — ichor) Virchow has proposed 
the name ichorrhwmia. O. Weber uses the name embolhcemia for the 
condition in which emboli are found in the blood. The classification 
given by Heuter, in his excellent work on this subject, appears to me 
very practical. In pure cases of purulent infection without metastases 
he calls the disease "pyohaemia simplex;" in cases with metastases, 
" pyohaemia multiplex." 

The course of purulent infection is usually acute (8-10 days), 
often subacute (2-4 weeks), rarely chronic (1-3-5 months). The ra- 
pidity of the acute cases is due partly to the intensity and frequent 
repetition of the infection, partly to the extent of the metastases 



PYEMIA. 381 

The chronic cases usually occur in very strong or tough patients, and 
the infection is only moderately intense, and not often repeated ; the 
metastases are in external parts, as abscesses in the cellular tissue, 
and suppurations of the joints, which keep the patient sick after the 
other results of purulent infection have disappeared. The prognosis 
essentially depends on the course. The more frequently the chills are 
repeated, the more rapidly strength is lost; the earlier the symptoms 
of internal metastases present themselves, the sooner the patient will 
die. The longer the intermissions between the exacerbations of fever, 
the better the strength is preserved ; the longer the tongue remains 
moist, the more hope we have of the patient's recovery ; he is not out 
of immediate danger till the wound again looks well, till he has been 
entirely free from fever for several days, and has otherwise the ap- 
pearance of a convalescent. It is exceedingly rare for a patient who 
presents all the above symptoms of decided pyaemia to recover. 

We must now go somewhat deeper into the etiology of traumatic 
infectious fever. At present there is probably no doubt that it is 
usually due to reabsorption of putrid fluid or pus ; that it is alicays 
so, is indeed disputed. Many surgeons assert that pyaemia very fre- 
quently results from miasma, especially from a miasma which develops 
from the wounds of many patients lying together ; this view is based 
chiefly on the fact that where many severe surgical cases lie together 
(as in large hospitals, especially army hospitals), many of them die of 
pyaemia, and that even mild cases, patients with cicatrizing granula- 
ting wounds, become pyemic under such circumstances. This is no 
place for polemics, hence I must be content with giving you my own 
views on the subject. I can entirely agree to the miasmatic origin of 
pyaemia, if by miasma is understood what I understand by it in the 
present and some other cases, namely dust-like, dried constituents of 
pus, and possibly also accompanying minute, living, very small or- 
ganisms, which in badly- ventilated sick-rooms are suspended in the air 
or adhere to the walls, bedclothes, dressings, or carelessly-cleaned 
instruments. These bodies, which are in some respects of different 
nature, are usually phlogogenous, all pyrogenous, when they enter the 
blood ; of course they will collect chiefly where there is the best oppor- 
tunity for their development and attachment, that is, in badly-venti- 
lated sick-rooms, where the patients are carelessly attended, where 
there is deficient cleanliness, and the patients remain some time in the 
same apartments. It is impossible to say whether all pus, moist or 
dry, is alike injurious ; experiments on animals give us no information 
on this point. It is only within the last ten years that the distinc- 
tion between pyaemia and septicaemia has been accurately made ; it 
is based on etiological, clinical, and anatomical grounds, as I have 



382 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

described. Now, objections are made to this distinction ; it is as- 
serted that the poison is the same in traumatic fever, septicaemia, 
and pyaemia, and that all are due to the growth of cocci. I can 
assure you, we know nothing certain about it ; possibly it is true, 
perhaps not. But the clinical appearance of these diseases gener- 
ally differs enough to separate them till we know more about them ; 
if it should be shown that the difference is due merely to more or 
less intense action of the same chemical process, it would be a beau- 
tiful scientific discovery, but would not detract from the clinical and 
prognostic value of the descriptions. From my own experience I 
can say that there are cases answering to those for which Sueter 
proposes the name " septo-pyaemia," where the symptoms of septi- 
caemia and pyaemia are mingled. The term " subacute pyaemia," 
used by Stromeyer and other older colleagues, corresponds to our 
septicaemia. What the French call " gangrene traumatique foudroy- 
ante " is a rapid decomposition and turning green of tissue, with 
great development of gas deep in the muscles, during the life of the 
patient. It is very rare ; I have seen two such cases after amputa- 
tions at the thigh for severe injuries. I consider the idea of animated, 
dust-like miasma a very fruitful one, and if in any of you it calls to 
life new thoughts, which lead to actual studies, the chief aim of my 
exertions as teacher is gained. The old doctrine of the gaseous form 
of miasmata has always led us into deep water ; many shrewd per- 
sons have exhausted their brains on this point, without advancing it 
much. Another common question is, Is pymmia contagious f Ac- 
cording to the view I have just given of pyaemic miasm, this is an- 
swered to some extent both in the affirmative and negative. A fixed 
molecular miasm, originating from a suppurating pyaemic patient, 
must at the same time be regarded as a fixed contagion ; but accord- 
ing to my view this miasm may just as well come from a non-j)yaemic 
patient ; then it cannot be termed contagious in a specific sense, for 
a contagion always induces the same disease. You see that the strife 
as to the contagiousness or non-contagiousness of pyaemia must go 
back to the views as to the nature of the disease ; it is only impor- 
tant for those surgeons who regard pyaemia as a peculiar specific dis- 
ease, not related to suppurative fever — a view which I regard as 
groundless and practically useless, and against which I have long- 
fought, and I hope with some success. With all these things arises 
the question, Does pywmic miasm enter the body only through the 
wound, or also through the shin and mucous membranes f Although 
the latter is not impossible, I have not yet made any certain obser- 
vations by which such an hypothesis can be considered proved or 
even probable ; but from my experience I hold to the opinion that 






PYEMIA. 383 

the infection of the whole body comes from the wound, whether the 
poison finds circumstances favorable to its development in the wound 
and surrounding parts, or whether it be introduced into the wound 
already developed. I am not shaken in this view even by those rare 
cases where there is no visible change, or only very little, in the wound 
on commencing pyaemia, for possibly the infecting body has very little 
if any phlogogenous action, and hence may enter the blood through the 
wound, and have a pyrogenous action, without causing any change in 
the wound at its entrance. Sex seems to have very little influence on 
the frequency of infectious diseases of this class ; possibly tempera- 
ment, the energy and frequency of the contractions of the heart and 
arteries, may have more influence on the reabsorption of the delete- 
rious substances. Judging from general impressions, children seem 
less disposed to pyaemia than adults. It would be exceedingly diffi- 
cult to make statistics on this point, as so few severe injuries occur in 
women and children as compared with men ; consequently, the fact 
that so many more men die of traumatic-infection fever of course 
proves nothing about the predisposition of either class to this disease. 
Open wounds of bone particularly dispose to pyaemia ; judging from 
my experience, those wounded in the lower extremity are most, those 
wounded in the trunk are least, in danger of becoming pyaemia 
The time of year and the collection of severely wounded in hospitals 
seem to have little if any direct influence on the development of py- 
aemia, unless by causing greater accumulation of infecting matter in 
the dressings, etc., thus increasing opportunity for infection. 

Lastly, I must mention the so-called spontaneous pyaemia. Cases 
occur where multiple abscesses (of the subcutaneous tissue, for in- 
stance), or even venous thrombi with embolic metastatic abscesses, ap- 
pear without our being able certainly to detect any primary point of 
suppuration ; these cases, especially if they run an acute course, are 
called spontaneous pyaemia. There is no reason for raising a new 
theory for these rare cases, where we simply fail to detect the primary 
point of inflammation ; I doubt not that there will hereafter be less 
mention of these cases, which, according to old theories, were very 
enigmatical, as we are constantly learning to observe more accurately, 
and, on more careful examination, shall usually find the connection of 
the symptoms. 

From the intimate relation, which we suppose to exist, between 
traumatic fever, septicaemia, and pyaemia, it seems correct to speak 
of the treatment of these diseases under the same head. This may 
be divided into prophylaxis, and the treatment of the developed dis- 
ease. The former is by far the most important ; it consists in avoid 



384 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

mg every thing that may favor the disease. Even in operations there 
are some points to be observed ; all the instruments used, the hands 
of the operator and his assistants, and the sponges (which should 
either be perfectly new or should be replaced by moist compresses), 
should be perfectly clean ; haemorrhages should be entirely arrested, 
especially if sutures are to be applied, and the wound is deep ; if the 
wound heals by suppuration, the compresses should be moistened with 
chlorine-water. In accidental injuries, all deep wounds, particularly 
if contused, should be kept quiet by dressings ; all that is necessary 
in compound fractures has already been said. Every thing that can 
excite secondary inflammation (page 165) should be most carefully 
avoided ; the patient should lie quiet, and as comfortably as possible. 
I would remind you of the treatment, previously given for contused 
wounds. Of course the greatest care must be used in dressing the 
wound ; here the greatest pedantry may be very beneficial. Hospital 
influences, which I only touch on here, are peculiarly interesting. 
Although few of you may have the fortune to control civil hospitals, 
any of you may desire knowledge on this point during war. Of 
course, hospitals should only be located where there is no marsh 
miasm. The hospital should be placed in a large, open space, with 
trees planted about it, and should have properly-located odorless wa- 
ter-closets. Of all artificial systems of ventilation, I think that Van 
HeTce's is the only one worth any thing. In it the walls of the whole 
building are traversed by canals, opening into every ward. All these 
canals start from cross-passages under the building, at whose points 
of intersection there is a sort of wind-mill, driven by steam, so that 
new air is thus constantly driven into the wards of the hospital (pul- 
sionssystem). If there be no artificial system of ventilation, we must 
do as well as we can with the so-called natural ventilation, i. e., cor- 
responding draught-openings should be made above and below in 
doors and windows, so that in their beds the patients may escape the 
draught as much as possible ; these ventilators should never be en- 
tirely closed. An excellent English surgeon, Spencer Wells, says : 
" There is only one true means of ventilation : the impossibility of 
closing doors and windows." I consider a proper use of the wards 
as important as their ventilation. No surgical ward should be used 
more than four weeks in succession ; it should then be emptied for a 
few days and carefully cleaned ; the walls should be painted with oil- 
paint so that they may be washed, or else they should be white- 
washed at least two or three times a year, more frequently if neces- 
sary. The beds should be frequently aired, shaken up, and sunned, 
and the straw in the sacks often renewed. Every surgical division 
should have one, or, still better, two supernumerary wards, so that 






TREATMENT OF TRAUMATIC FEVER, ETC. 385 

they may be regularly occupied in turns. With the same object, 
there should not be more than six or eight beds in one ward, so that 
enough patients may be discharged every week to empty one room. 
The new patients should always be brought into the ward last 
cleaned. This is the only way to prevent the extensive development 
of miasm in hospital. To attain the best possible results in hospital 
we must have plenty of room, and plenty of money for nurses, linen, 
etc. We can thus use even badly -located hospitals. Large wards, 
with twenty or thirty beds, which, from press of patients and other 
causes, cannot be emptied at will, are very unsuitable. The director 
of a surgical division should, above all things, have at his disposal a 
large number of well-ventilated rooms of medium size, which can be 
emptied and cleaned at certain times. Bad hospitals, and especially 
badly-kept rooms for surgical patients, are worse than the poorest 
tenements ; they may become slaughter-pens for the wounded. Sur- 
geons should never forget that they themselves are often to blame if 
their patients have erysipelas, hospital gangrene, diphtheria, etc. ; for, 
if, after old customs, we ascribed every thing to the invisible, omni- 
present, intangible, ethereal miasm and genus epidemicus, it would be 
death to all our future progress. 

Coming now to the treatment of traumatic fever, septicaemia, and 
pyaemia, we may say that, for simple traumatic and suppurative fever, 
which does not pass the usual limits, we generally use nothing but 
cooling drinks, fever diet, and a little morphine at night to secure 
good rest. If the fever lasts longer, or assumes a peculiar character, 
we may resort to febrifuges. Digitalis is here of little use, on account 
of its slow, uncertain action. Veratria reduces the temperature, but 
appears to do little good in toxic traumatic fevers ; still, further obser- 
vations must be made on this point, especially in pyaemia. The ac- 
curate studies of JBiermer show that this remedy should be used very 
carefully. Formerly aconite was highly recommended in pyaemia by 
Text or. I have seen no good from it. Quinine is the most effica- 
cious remedy for the intermittent suppurative fever, especially in com- 
bination with opium ; 6-8-16 grains of quinine in the course of the 
afternoon, and one grain of opium at night, often arrest the chills ; in 
severe suppurative fevers I employ these remedies with benefit ; in 
decided pyaemia they do less good. After careful observation, Lieber- 
meister found that quinine only showed its antifebrile action in typhus 
and other infectious diseases with certainty when given to the extent 
of fifteen grains or more daily. There are plenty of observations, too, 
on remedies for directly opposing the blood-poisoning. I have found 
no effect from the antiseptic internal remedies, the acids, chlorine-wa- 
ter, and sulphurets of the alkalies (which are greatly praised bv Polli). 
25 



386 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

But we may also use other remedies, intended, by increasing the 
change of tissue, to separate the organic poison from the blood. See- 
ing the profuse diarrhoea in dogs artificially made septicaemic, and 
finding them to recover frequently after these diarrhoeas, we might 
suppose the poison to be most naturally excreted through the intes- 
tinal canal. In fact, Breslau has had favorable results from repeated 
doses of laxatives in puerperal fever. I am sorry not to have had 
similar experience in pyaemia. In this disease diarrhoea is a severe 
complication, which quickly induces collapse. It might also be 
thought advisable to increase the secretory activity by giving emet- 
ics ; but they are followed by such collapse that we must be careful 
in their administration. In septicaemia I have often tried to induce 
profuse perspiration, when the skin was very dry. This was occasion- 
ally done by a warm bath, lasting for an hour, and then wrapping in 
blankets. This occasionally does good ; indeed, I think patients have 
thus been saved that I had thought incurable. Further trials should be 
made with this remedy. Copious diuresis also may be induced by 
plenty of drink, but it has not much effect on the general condition. 
Lastly, we might think of arresting the further absorption of inju- 
rious substances from the injured or inflamed part by amputation, 
even after the appearance of severe constitutional symptoms. In 
acute cases of septicaemia and pyaemia this very rarely has a perma- 
nently beneficial effect, although there is almost always temporary 
improvement. But in subacute and chronic pyaemia amputation 
may, indeed, save life ; unfortunately, however, such cases are rare. 

So we finally come back to what we said at first, that much may 
be done to prevent severe traumatic and suppurative fever, but that 
there is little to be hoped from treatment of these diseases when 
fully developed. 22 



LECTURE XXVII. 

4. Tetanus; 5. Delirium Potatorum Traumaticum; 6. Delirium Nervosum and Mania. — 
Appendix to Chapter XIII. — Poisoned Wounds ; Insect-bites, Snake-bites ; Infec- 
tion from dissecting Wounds. — Glanders. — Carbuncle. — Hydrophobia. 

The group of diseases which belong to the traumatic and phlogistic 
infectious conditions, and of which we still have to speak, comprises 
tetanus, drunkard's madness, and the psychical disturbances which so 
rarely occur after injuries and operations. The views, as to their ori- 
gin, vary greatly ; as, from their symptoms, the processes in question 
would be referred to irritation of the brain and spinal cord, their cause 



TETANUS, 387 

is usually sought m the nervous centres. But it is known that by 
blood-poisoning, with strychnine, severe spasms, and with alcohol, 
psychical disturbances (drunkenness) may be induced ; hence, it is 
very possible that the following forms of disease may result from 
poisoning with peculiar substances, which possibly are very rarely 
formed in wounds, and thence absorbed, while in drunkard's mania a 
series of ordinary pyrogenous materials may excite certain disturb- 
ances (namely, fever with peculiar, predominant psychical disturbances) 
in the organism already poisoned by alcohol. The symptoms that we 
shall see in these diseases are all present in ordinary fever, although 
to a slighter and less prominent degree ; in the combination of the 
affected muscles, chills have an undoubted similarity to tetanus, psy- 
chical disturbances, even to maniacal attacks, occur as so-called fever 
delirium in some cases of septicaemia, but especially in typhus. In de- 
scribing the individual diseases, we shall occasionally recur to these 
remarks, for which, unfortunately, we have no experimental foundation. 

4. Traumatic Tetanus [Trismus). — This disease, which consists in 
spasms of the muscles of the jaw alone (trismus), or of all the muscles 
of the body (tetanus), the muscles of the extremities being most affected 
sometimes, at others those of the front or back of the trunk, occasion- 
ally occurs in the wounded ; though it is rare in proportion to the 
traumatic diseases above described, it occurs still more rarely in per- 
sons without wounds. In large hospitals, years may pass without a 
case of tetanus being seen ; again, at certain times, numbers of cases 
will appear, so that there has been an inclination to seek an epidemic 
cause. The disease is by no means confined to hospitals, but comes 
either in or out of them. However, before discussing the etiology, I 
will try to give you a brief description of an acute case. 

The third or fourth day after an injury, rarely sooner, often later, 
you find that the patient cannot open his mouth well when speaking, 
and complains of tearing, drawing pains, and of stiffness in the masti- 
catory muscles. In very acute cases there is high fever even with 
these first symptoms, in other cases the patient is free from fever at 
this stage. The lines in the patient's face gradually assume a pecu- 
liar, stiff expression, the facial muscles being to some extent spasmod- 
ically contracted. Subsequently there are tetanic spasms, which may 
affect the trunk or extremities ; in some cases these last several sec- 
onds or minutes, and are induced by any external irritation, just as in 
hydrophobia. These spasms are accompanied by severe pain. Occa- 
sionally, from first to last, some groups of muscles remain regularly 
but painlessly contracted; in some patients the twitchings (shocks 
of Hose) are entirely absent, and there is only permanent contraction 
of more or less distinct groups of muscles. Not unfrequently the 



388 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

patient's body is bathed in sweat, his mind being clear ; occasionally the 
urine contains albumen ; sometimes the fever rises to a height that 
is rarely seen, even to 104° Fahr., or over. But I have seen cases 
of trismus prove rapidly fatal, without the temperature becoming ele- 
vated ; Rose has made similar observations. Death may occur within 
twenty-four hours from the commencement of the disease, but the lat- 
ter may also last with considerable severity for three or four days ; 
these cases also are to be classed among the acute. There is a more 
subacute or chronic form of trismus, and of trismus and tetanus, in 
which there is merely a gradual development of a moderate trismus 
and of contractions without pain, extending to single groups of mus- 
cles of the injured limb. In these chronic cases fever is usually en- 
tirely absent. It is rare for an acute case to become chronic. 

All the symptoms indicate that there is an irritation of the spinal 
medulla and of the portio minor of the fifth pair. The symptoms re- 
semble, although remotely, those which may be induced by poisoning 
by strychnia. Unfortunately, the results given by autopsy of these 
patients are usually very unsatisfactory ; in the acute cases, especially, 
nothing can be found in the spinal medulla ; in cases of some days' 
duration, Rokitansky claims to have seen a development of young 
connective tissue in the spinal medulla, which would make it appear 
that there was an inflammatory aifection of this nerve-centre. My ex- 
aminations of the spine and nerves in tetanus have thus far given only 
negative results. In preparations made from cross-sections of the 
spinal medulla, and sent to me by excellent specialists in examining 
the nervous system (Dr. Gott, in Zurich, and Dr. Meynert, in Vienna), 
I saw the connective tissue remarkably developed at some places, it is 
true ; but, as there was no collection of young cells, I was in doubt 
whether this increase of connective tissue was really new formation, 
or was due to mere accidental swelling. The symptoms during life, 
in cases where we find decided evidences of spinal inflammation, are 
so different from tetanus as to render it improbable that the latter de- 
pends on myelitis spinalis. The discovery of small extravasations of 
blood in the muscles and nerve-sheaths, on autopsy, shows little about 
the nature of the disease, for they may be caused by ruptures of the 
capillaries during the great muscular contractions. 

There are many views as to the causes of this disease, as there 
usually are about affections with no anatomical, pathological charac- 
teristics. At first, it was natural to examine the nerves, and in many 
eases the nerve-trunks are crushed by the injury, or torn or irritated 
by foreign bodies. I myself have seen some such cases ; a few years 
since, I saw a sporadic case where, in an open splintered fracture of the 
lower end of the radius, the median nerve was half torn through ; the 



TETANUS. 389 

third day trismus and tetanus appeared suddenly, and proved fatal in 
eighteen hours. It is no use to build theories as to how this particu- 
lar variety of injury of the nerves should induce tetanic spasms, whilf 
they are very rare after simple division of the nerves, for there are 
many cases where tetanus has arisen from simple wounds of the skin, 
from granulating surfaces fully developed and cicatrizing, or even 
after a blister, the sting of a bee, etc. It is, however, remarkable that 
the disease is particularly frequent after injuries of the extremities, 
especially of the hands and feet, while it is rare after considerable 
injuries higher up the limb and on the body. I also think that I have 
found the cases, where tetanus developed from granulating wounds, tc 
be more chronic and milder than those where it has developed soon 
after the injury. Hose thinks that tetanus appears particularly in 
cases that are treated badly or not at all ; my experience is opposed 
to this. After applying in vain to the nerves and tendinous tissue, 
the various changes of temperature were resorted to to explain the 
occurrence of tetanus ; some said that it was favored by hot, sultry 
weather. I cannot altogether deny this view, for hitherto I have only 
seen numerous cases of traumatic tetanus in hot, sultry weather, but 
small epidemics of it have been seen in winter. Others ascribe the 
chief blame to catching cold from draughts or to rapid changes of tem- 
perature. Finally, there are still others who do not believe that the 
nervous system is primarily affected, but think that the blood first 
becomes diseased and acts secondarily on the nervous system. Within 
a short time Hose has resurrected an old idea, that tetanus, like hydro- 
phobia, is to be regarded as a primary blood-disease. It cannot be 
denied that the two diseases are much alike ; a proof of their being 
actually analogous would be most strikingly given by inducing hydro- 
phobia, by inoculating animals with the blood or secretions from a 
tetanus patient. Of course, we should not think of inoculating another 
man. At present, I strongly incline to the humoral view of tetanus 
as due to a peculiar poison, although I have no proofs of it. At all 
events, the blood of a tetanus patient should be injected into a dog, 
to show whether tetanus may be transferred through human blood to 
a dog, and also whether it has a pyrogenous action ; should tetanus 
appear in the dog, it might be regarded as proved that tetanus was a 
humoral disease ; if the experiment be negative, it proves nothing 
against the humoral causes of tetanus, it only shows that the blood of 
a man with tetanus will not induce tetanus in a dog • it would still 
have to be decided whether the blood of a dog with tetanus, trans- 
ferred to another dog, would prove as inactive. The fact that tetanus 
may be confined to one limb, or even to one hand as I have seen it, 
speaks in favor of a local cause, which may be limited to the nerves ; 



390 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

but there are also a localized lymphangitis, localized erysipelas, etc. ; 
the fact that, after amputation, for instance, twitching not unfrequently 
occurs in the stump before the spasms become general, might also 
indicate that the tetanus-poison formed in the wound first irritated 
the muscles and nerves of the stump, and then passed to the spinal 
medulla. There still remains much to be investigated on this point. 
The high fever in most cases of acute tetanus, and the fact that the 
temperature rises even after their death, has greatly occupied pathol- 
ogists ; this became still more interesting when Leyden showed that 
great elevation of the temperature of the blood was caused in a dog 
in which tetanus had been artificially induced by passing a strong 
current of electricity through the whole spinal medulla. A. Fick 
showed that a surplus of heat was formed in the muscles, and thence 
distributed to the blood ; also that the elevation of temperature, noticed 
in the rectum after death, was due to the equalization of warmth 
between the muscles and the rest of the body. If these experiments, 
which I have repeated, prove that tetanic muscular contractions con- 
siderably elevate the bodily temperature, they do not show that in 
traumatic tetanus in man the high temperature is solely or chiefly 
due to the muscular contractions ; this view is opposed by the fact 
that very acute cases of tetanus may run their course almost without 
fever, although this rarely happens ; here, too, there are many enigmas 
to solve. 

Unfortunately, in most cases the prognosis is bad ; very few of 
the acute cases recover ; of the chronic cases, which last over a fort- 
night, some get well. Unfortunately, the latter are proportionately 
rare. 

From the lack of knowledge about the etiology of this disease, the 
treatment can be only symptomatic. Numerous remedies have been 
recommended at various times. Generally, the treatment most resorted 
to is by narcotics, with opium and chloroform ; this is the plan I have 
adopted. Opium is given in large doses, as high as fifteen grains or 
more in a day, or a corresponding quantity of morphine may be given, 
best by subcutaneous injection ; sometimes this arrests the spasms, 
sometimes it does no good. At all events, the sufferings of the pa- 
tient are lessened. During the attacks the patient may be greatly 
relieved by inhaling chloroform to narcotism. Under this treatment 
many cases have recovered. The general aim of the treatment is to 
alleviate the acute course, and make it more chronic, as this gives 
more hope of recovery. Among other modes of treatment, I may 
mention the frequent employment of warm potash-baths ; and the 
application of strong irritants along the spine, large blisters, moxae. 
the hot-iron, remedies from which I cannot promise any good effects , 



DELIRIUM TREMENS. 391 

and, lastly, the curare, which is of late occasionally used, has not 
answered the hopes that some had of it. 

In the chronic cases you need not employ any special treatment ; 
the patient remains in bed, and should keep perfectly quiet ; he should 
be guarded against all injurious influences, especially from physical 
or mental excitement. 

5. Drunkard?* madness. Delirium potatorum traumaticum. 
Delirium tremens. — We now come to an enemy of the wounded 
which, fortunately, is not very dangerous. You have doubtless heard 
of delirium tremens, the acute outbreak of chronic alcoholic poisoning, 
which may come on spontaneously, or from some acute diseases, es- 
pecially pneumonia. Injuries are a frequent cause. You will become 
better acquainted with this disease from the lectures on medicine ; as 
the attacks, from whatever cause they arise, are much alike, I shall 
be very brief on this point. 

The disease generally breaks out within two days after the injury, 
in some rare cases it is longer. It only attacks patients who have for 
years been accustomed to the free use of alcohol, especially of schnaps 
and rum ; but it is an error to consider beer and wine drinkers exempt 
from delirium. The first symptoms are sleeplessness, great restless- 
ness, trembling hands, unsteady look, tossing about in bed, and talka- 
tiveness, and then delirium. The patients talk constantly, see small 
animals, midges, flies, etc., swarming about them ; mice, rats, mar- 
tins, foxes, etc., crawl from under their beds ; they think they are in 
a smoky atmosphere, and feel dizzy. The delirium often has the 
most comical form ; a soldier, whom I treated in Zurich for delirium 
tremens, saw numbers of other soldiers in his water-glass ; when I 
entered the room, he spoke lowly to my assistant, taking me for his 
major, etc. Generally the hallucinations are of a happy nature, never- 
theless, the patients are tormented with restlessness, constantly toss 
about in bed, and wish to get up. If we have not two stout nurses 
to hold these patients, there is often no way of avoiding the applica- 
tion of a strait-jacket and tying them in bed. These patients are 
usually good-natured in their delirium, and if spoken to emphatically 
they give sensible answers, but soon fall back into their wanderings. 
Of all kinds of injuries, fractures, especially open fractures, most fre- 
quently give rise to the outbreak of the disease, and, before we had 
firm dressings for such patients, it was a difficult task to fix the broken 
limb, as the patients did not notice the pain, and moved the limb so 
forcibly that any splints were loosened in a few hours. Even where 
there is marked delirium, the prognosis is not unfavorable, according 
to most surgeons ; from my somewhat meagre observations, I cannot 
agree in this opinion : of the patients with acute delirium tremens that 



392 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

1 have treated, at least the half have died ; they often declined suddenly, 
became unconscious, and soon died. Others recovered, especially when 
it was possible to make them sleep a while ; this is the object of the 
treatment ; opium in large doses is the almost universal remedy, for 
it we may substitute small doses of tartar-emetic. After this the 
patients fall into a comatose state, from which in favorable cases they 
awake cured, but sometimes sleep on till death. I can recommend no 
better remedy than opium in delirium tremens, although I must ac- 
knowledge that in large doses (gr. ii. — vi. every two hours till sleep is 
induced), I do not consider it free from danger [of late, hydrate of 
chloral, in doses of gr. xx. — 3 i, is said to have been given with great 
benefit in such cases ; it is claimed that it acts well not only on the 
delirium tremens, but on the fever which so often accompanies the in- 
jury]. Of late, there has been a great outcry in England against the 
opium and tartar-emetic treatment, and a more expectant treatment 
has been recommended. Others have had good results from digitalis ; 
most surgeons are well satisfied with the opium-treatment, and the 
coincident administration of strong wine and cognac has been highly 
recommended. The more chronic cases of delirium potatorum, with- 
out maniacal attacks, have seemed to me of more favorable prognosis ; 
there, strong grog is useful ; I give the following mixture : one yolk 
of egg, one ounce of arrack, four ounces of water, two ounces of sugar ; 
this does not taste badly, and may also be used as a stimulant for old 
persons (a tablespoonful every two hours). I must warn you against 
abstracting blood, which is very dangerous in drunkards, and not un- 
frequently induces collapse terminating in death. 

Autopsy of patients who have died of delirium tremens shows no 
special cause of death ; we find the changes common to topers ; 
chronic gastric catarrh, fatty liver, Bright's kidneys, thickening of the 
meninges of the brain, but no constant changes in the brain-substance 
proper. 

6. Delirium nervosum and psychical disturbances after injury. — 
By delirium nervosum traumaticum we mean a state of excessive 
nervous exaltation without fever, occurring after injury ; this is said 
particularly to affect hysterical persons. I have only seen one case to 
which I could apply this name : a man twenty-four years old (from 
Canton Thurgau, the land of perry), who had never been accustomed 
to drinking, after a fracture of the leg, complicated with a slight 
wound, soon had delirium without fever, like an old toper ; the fan- 
cies referred to the same subjects as in delirium potatorum, passed 
off under quieting treatment and opium, without maniacal attacks ; 
after four days the delirium ceased, and the patient remained reason* 
able. Lastly, T must mention those rare and interesting cases where, 



POISONED WOUNDS. 393 

after operations in otherwise healthy persons, psychical disturbances 
develop, cases which evade all attempts at explanation, and are only 
analogous to cases where, after acute diseases, such as pneumonia, 
acute rheumatism, or typhus, the development of true mania is ob- 
served. In the Berlin surgical clinic I saw tw^o such cases, in both 
of which, after total rhinoplasty, there was melancholy with religious 
hallucinations. Both patients were Catholic : one, a young man, in- 
cessantly worried himself trying to understand the idea of the TrinhVy ; 
the other patient, a young woman, sought by prayers and castigations 
to atone for giving way to her vanity so far as to have a new nose 
made to replace the one lost by lupus. In the young man there were 
frequent outbursts of rage ; both patients perfectly recovered after a 
few weeks. I have heard that Von Langenbeck, in Berlin, had an- 
other such case after a plastic operation, and Von Grclfe and JEs- 
march have had them after operations on the eyes. But these cases 
are very rare. 



APPENDIX TO CHAPTER XIII. 



POISONED WOUNDS. 



We have still to treat of some varieties ot injuries, where at the 
time of the injury poison is inoculated, which sometimes induces 
severe local symptoms, sometimes dangerous general disease. It is 
well known that these poisons are peculiar to some animals, and in 
others they develop as a result of certain diseases, and are then trans- 
ferred by the diseased animal to man. 

The results from punctures of a large number of small insects are 
scarcely in proportion to the slight mechanical irritation caused by their 
stings; it may, it is true, depend partly on peculiar susceptibility of the 
skin, if persons have extensive temporary inflammations of the skin after 
bites by bugs, midges, or fleas, while others are not affected by them. 
A needle-puncture is a much greater injury than a flea-bite, but the 
latter is followed by itching and burning, and the formation of wheals 
on the skin, while the results of the former amount to nothing. Hence 
it is not improbable that in the case of the wound made by the insect 
some irritating substance enters the skin. As is known, the stings of 
bees and wasps excite even greater disturbances ; occasionally there 
is an extensive, very painful inflammation of the skin, with great red- 
ness and swelling, which usually terminates in resolution, and does 
not prove dangerous, but may be very annoying. A large number of 
such stings at the same time is not altogether free from danger ; such 



394 TKAUMATIO AND INFLAMMATORY DISEASES, ETC. 

stings on the tongue, in the palate, or on the eyelids, may from their 
locality cause certain dangers by the swelling induced. But, as these 
inflammations subside in a relatively short time, a physician is rarely 
called ; the popular treatment is by various cooling remedies to allevi- 
ate the pain, among which I shall merely mention the application of 
moist clay, raw mashed potato, cabbage-leaves, etc. In more severe 
inflammations, lotions of lead-water and other antiphlogistic remedies 
may be resorted to. Still more severe than the stings of bees and 
wasps are those from tarantula? and scorpions, that are seen in southern 
countries. They are followed by more extensive inflammation of the skin, 
with severe burning pains, occasionally by formation of vesicles ; there 
may also be fever, but there is usually no danger, unless it arise from 
the locality of the injury. The treatment should be that above given. 

Fortunately, with us there are few varieties of poisonous serpents, 
and even they are not frequent. Among them are the "Vvpetra JSerus 
(cross adder), and Viper a Hedii, with two hook-like, curved fangs, 
containing the excretory ducts of small glands, which, at the time 
of the bite, pour their poison into the wound. The bite of these ser- 
pents is not so dangerous as is supposed; according to statistics, 
about two die out of sixty persons bitten. The pain is very severe ; 
there are great inflammation, tension and swelling of the skin, with 
high fever, great anxiety, depression, vomiting, and occasionally 
slight icterus. The best treatment is to suck out the wound at once, 
as the poison is not absorbed by the gastric or oral mucous membrane. 
The wound should be washed at once, and it is advised to ligate the 
injured limb above the wound to prevent the absorption of the poison ; 
but this has usually taken place by the time the patient reaches the 
surgeon ; it is a disputed point whether the application of cups, the 
cauterization, burning or excision of the wound, be now of any ser- 
vice, but I should think its cauterization advisable. The local cutane- 
ous inflammation is treated with special attention to the intense pain ; 
by applications of oil, protecting the skin from the air by various rem- 
edies, with which we become acquainted in the treatment of superfi- 
cial burns. Internally we usually give an emetic, then antiseptic 
remedies. Of all snake-bites in southern countries, those of the rattle- 
snake are most dangerous ; sometimes they prove fatal in a few hours ; 
the local inflammation of the skin, which is very severe and extensive, 
not unfrequently ends in gangrene ; those bitten die with high fever, 
delirium, and sopor. [Prof. Halford, of Australia, treats snake-bites 
by injecting diluted liquor ammonias into the veins. See London 
Medical Times and Gazette, 1869, page 123.] 

Cadaveric poison is a very phlogogenous substance, which proba- 
bly varies greatly in its chemical composition. Some of you may have 



POISOXED WOUNDS. 395 

already had some experience on this point, in the dissecting-rooms. 
This putrid poison develops in the corpses of men and animals; if, in 
handling these, some of the juice from the dead tissue enters small, 
insignificant, and scarcely noticeable injuries of the skin, very dis- 
agreeable symptoms may develop. The resulting conditions are vari- 
ous, sometimes very malignant. Cases occur which were formerly 
seen particularly often in England, where at first there is little pain in 
the wound, but there are great depression, headache, fever, and nausea ; 
then come delirium and sopor, and in some cases death takes place in 
forty hours. It is asserted that these worst cases of septicaemia were 
most frequent, from autopsies made soon after death, on bodies still 
warm, and it was doubtful if in these cases the surgeon had not inoc- 
ulated himself with morbid matter developed in the body while still 
living, for the state usually termed putrefaction could not have begun. 
As a contrast to this malignant acute form, we may regard those cases 
where the poison has a purely local action. In the course of twenty- 
four hours there are moderate pain and slight induration in the injured 
finger; then a dry scab forms on the wound; under it there is always 
some pus. The scab forms as often as it is removed, the part remains 
painful and hard ; in the course of time the epidermis thickens over it, 
and it forms a painful, wart-like nodule, moist on the surface. One in- 
clined to this purely local development is usually less disposed to 
general infection. Between these two forms stands a third, where an 
inflammation of the lymphatic vessels and axillary glands accompanies 
the local inflammation ; under early treatment this may end in resolu- 
tion, but it often leads to abscesses in the arm. 

For the first treatment of the part poisoned by cadaveric matter, 
I advise you to let cold water run on the wound for a long time, and 
not to check the bleeding, if there be any. In many cases the injurious 
matter will be at once washed out, and there will be no further infec- 
tion. Should the parts around the wound redden, you may cauterize 
with nitrate of silver or fuming nitric acid ; this is very painful, but it 
acts well ; not unfrequently pus forms again under the resulting slough ; 
in this case you remove the slough, and cauterize again, and repeat this 
till no pus forms under the slough. 

Cauterization immediately after contact with the poison, from a 
considerable experience on myself and on my students in the course 
on operations, I consider unadvisable. Small, lacerated wounds that 
do not bleed, and excoriations, are always more dangerous for infec- 
tion than deeper incised wounds ; the anatomical reason for this is 
that the lymphatic net-work lies chiefly in the most superficial layer 
of the cutis. Moreover, the susceptibility to the poison varies with 
the individual ; repeated infections appear rather to increase than to 



396 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

diminish the predisposition. Should lymphangitis begin, the arm 
should first of all be placed on a splint to keep it quiet, and then the 
treatment previously recommended for lymphangitis instituted. You 
may consider the course in the appearance of the above morbid symp- 
toms to be as follows : A small quantity of liquid from the cadaver 
(or even of putrid pus from a living patient) is introduced into the 
wound ; the lymphatic capillaries that have been opened take up this 
putrid matter and pass it into the trunks of the lymphatic vessels ; 
coagulation may quickly take place here, and then the putrid matter 
acts as a specific irritant only on a small part ; in other cases it acts 
on the lymph as a ferment, and the lymph coagulates in the next 
lymphatic glands, or else the swelling of the gland compresses the 
intra-glandular lymphatic vessels and so obstructs the passage 
through the gland ; in this case also the disease remains local, al- 
though extending some distance, and not unfrequently leading to 
suppuration with fever (as in other non-specific inflammations). 
Lastly, the rarest cases : the fermented lymph, which even yet acts 
as a ferment, passes into the blood, and there excites chemical 
changes. Then we have a septicaemia, from cadaveric poison. From 
the cases that end in recovery we see that the injurious substances 
developed by the process may be again eliminated from the body by 
the secretions and excretions, but we do not know in what particu- 
lar way this is done. In some cases some putrid substance is encap- 
sulated in a lymphatic gland or other inflamed part, and may there 
lie harmless and after a time be gradually eliminated ; but on active 
movement the poison may be again driven into the lymphatic vessels 
by the increased pressure of the blood, and there induce new, acute, 
local, and general infection. If indurated lymphatic glands remain 
after infection with cadaveric poison, daily warm baths are the best 
means for promoting the excretion of the poison. 



We have still to treat of some poisons which in certain diseases 
develop in animals, and may thence be transferred to man. Under 
this head come glanders, carbuncle, and hydrophobia. 

Glanders (maliasmus, morve) is a disease which develops prima- 
rily in horses and asses. It is an inflammation of the nasal mucous 
membrane, in which this membrane becomes very thick, and secretes 
a thick, tough pus, and where, by the breaking down of caseous nod- 
ules, ulcers with a caseous base form ; swellings of the lymphatic 
glands, occasionally tubercle-like nodules in the lungs, and acute ma- 
rasmus, occur, and acute cases are usually fatal. The more chronic and 
milder form of glanders is called " farcy ; " it is rarer, and gives a 



CARBUNCLE. 397 

better prognosis. The glanders and farcy of animals are only con- 
veyed to man by accidental inoculation. If some of the pus of a glan- 
dered horse enters a wound or excoriated spot on a man, or if very in- 
tense poisonous glander-pus fall on the uninjured skin at a point where 
the epidermis is thin, there may be very acute inflammation with gen- 
eral septicaemia, which in most cases proves fatal. The chronic form 
of glanders is rare in man ; the symptoms are chiefly pustulous inflam- 
mations of the skin, and formation of abscesses at different points in 
the subcutaneous tissue ; it is not so dangerous. In some cases of 
acute glander-poisoning there is lymphangitis and suppuration, limited 
to the injured extremity ; in others a diffuse erysipelatous redness of 
the skin with great swelling develops quickly, while at the same 
time there is very intense fever. The local inflammation may go on 
to gangrene ; there is delirium, and soon coma occurs ; there may 
also be diarrhoea, purulent discharge from the nose, and pain in the 
muscles, with which symptoms the patient dies. The disease may 
run its course very rapidly ; I remember, when a student in the Got- 
tingen clinic, seeing a strong, robust man die of glanders in a few 
days ; but patients with acute glanders may live from ten to fourteen 
days, and all the symptoms of pyaemia may develop in them, and nu- 
merous haemorrhagic abscesses form in the muscles, which are so 
characteristic of glanders that they confirm the diagnosis. In rare 
cases acute, rapidly-fatal glanders may develop from the chronic; 
the reverse is also seen. Of course, persons that have much to do 
with horses are chiefly exposed to this disease, which never occurs 
primarily in man. Unfortunately, there is little hope from treatment 
in this disease ; as in acute pyaemia, we treat the most prominent 
symptoms. Iodine, arsenic, and creosote, have been recommended as 
antidotes in glanders. 

Carbuncle (anthrax, pustula maligna) is an infectious disease oc- 
curring primarily most often in cattle. It is called in German 
" Milzbrand " (gangrene of spleen), because in animals that have 
died of it the spleen is found greatly swollen, dark red, and gangre- 
nous ; in many cases also the intestinal mucous membrane is bloody- 
red and swollen ; the loose subperitoneal cellular tissue, and occa- 
sionally the subcutaneous cellular tissue, of one of the limbs is often 
the seat of brawny infiltration ; in the intestinal mucous membrane, 
and sometimes in the skin, carbunculous infiltrations may occur. As 
in all infectious diseases, the course varies in rapidity according to 
the amount and intensity of the poison absorbed and the resisting 
powers of the patient ; it may be foudroyante (apoplectiform), or 
may go on for several days. The herbivora are more readily infected 
than omnivora or carnivora. The contagion adheres to the products 



398 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

of the disease and the patient. Nothing certain is known about the 
origin ; since it is more frequent in some regions than others, it has 
been thought that the soil and food had some effect. The intestinal 
secretions are mixed with the dung of the animals, and their poison- 
ous effects have been proved. If such dung be spread over the land, 
and, either fresh or dried on hay, be eaten by other animals, they 
may be attacked by the disease. 

Transfer of the affection to man is most often through the matter 
of the pustule ; if this or the dried skin of the dead animal be brought 
in contact with the skin of man, even if it is uninjured, the poison 
may enter through a hair-follicle or sweat-gland ; the result is a pus- 
tule, at first unnoticed, then itching and burning, in the centre of 
which a black blood-blister soon forms ; high feYer soon comes on. 
In bad cases the cutaneous inflammation early assumes the character 
of carbuncle, terminating quickly in gangrene, and if left to itself the 
disease is usually fatal. 

Internally we give the ordinary antiseptics ; the anthrax itself is 
to be energetically attacked by incision, excision, caustic potash, 
nitric acid, etc. If the patient comes under treatment early and 
there is no intense blood-poisoning, there is hope of cure ; if the pus- 
tule is fully developed and septic symptoms have begun, death is 
certain. Recent observations show that infection in veterinary sur- 
geons from post-mortem examinations of diseased animals does not 
have such a dangerous course, but often gives rise to a phlegmon of 
medium intensity, which may pass off in a few days with scaling off 
of the skin. Quite lately Leube and W. Mutter have described cases 
where severe intestinal inflammation ending fatally followed the use 
of flesh from animals that had died of carbuncle. According to Zol- 
linger, the milk of cows with this disease proves infectious to man. 
It is still a disputed question whether malignant pustule may also 
develop primarily in man; whether the malignant carbuncle de- 
scribed in Lecture XXI. always comes from infection, or may come 
spontaneously from the same causes as in animals. Eminent sur- 
geons and veterinarians have investigated this subject ; inoculations 
of secretion from malignant carbuncles of man on animals have proved 
very uncertain ; observations have been contradictory ; in short, the 
relation of these different forms of carbuncle and pustules to each 
other, in regard to their etiology, has not yet been cleared up. 

Of late the view that the septic poison of carbuncle is associated 
with certain small organisms is gaining ground. Davai?ie especially 
holds that the bacteria (first described by Pollender in 1855) quite 
constantly found in the blood of living animals with carbuncle, or of 
those that have died of this disease, are the cause of the affection. 






CARBUNCLE. 399 

But we may doubt if it cannot exist without bacteria, as it is asserted 
that with blood from carbunculous animals, which contains no bac- 
teria, other animals may be infected. In Leube's cases, already men- 
tioned, countless cocci and bacteria were found in the intestinal mu- 
cous membrane (mykosis intestinalis, Buhl). Many assert that the 
bacteria found in carbuncle differ from those resulting from decompo- 
sition. Bollinger asserts that small cocci (bacteria germs) exist in 
the blood of every animal affected with carbuncle, but that from 
their small size they often escape observation ; he considers their 
vegetation as the essential cause of the disease, which is, however, 
favored by the species of the animal, its nourishment, and the char- 
acter of the soil and stabling. My own observations have shown 
me that the bacteria of carbuncle, like those in the blood and peri- 
cardium of decomposing bodies, belong to the meso- and megalo-bac- 
teria ; and also that cocci and even permanent germs (Dauersporen) 
often form in them. On inoculating blood containing bacteria in the 
cornea of rabbits, Frisch saw stellate figures form, evidently com- 
posed of bacteria, which developed enormously and led to suppura- 
tion of the eyeball, but never to general infection or the death of the 
animal. The inoculations of blood from horses and cattle w T hich had 
shortly before died of carbuncle on rabbits, Guinea-pigs, sheep, and 
dogs, in the cases I witnessed, proved more certain in proportion to 
the certainty of the presence of bacteria ; and uncertain results oc- 
curred, as they did in the cases of other observers. 

We must also mention the mouth and hoof disease of cattle, 
as recent observations have proved its transfer to man. In cattle 
the disease consists in the formation of vesicles and pustules on the 
mucous membrane of the mouth, at the roots of the hoof, and on the 
udders of cows ; these heal spontaneously in from five to fourteen 
days ; and although the animals often emaciate greatly, only the 
young ones ever die. The disease seems to spread epidemically 
through the secretion from the pustules, the milk, and perhaps also 
through an evanescent contagion. The transfer of the affection to 
man results from contact of abrasions of the skin with the matter 
from the pustules, or from free use of uncooked milk of the diseased 
animals. If the latter has been the mode of origin, vesicles and pus- 
tules form in the mouth and on the hands and feet, as in the cattle. 
Catarrh of the throat and stomach may be added. The treatment 
consists in frequently rinsing the mouth, painting the vesicles with 
solution of borax (five parts to thirty of honey), and touching the 
pustules on hands and feet with nitrate of silver. Cooking destroys 
the infecting matter in the milk. It is not improbable that some 
aphthous diseases of small children arise from infection by milk thus 



400 TRAUMATIC AND INFLAMMATORY DISEASES, ETC. 

diseased. In man the disease runs its course without much danger, 
as it does in cattle ; only very young, feeble children could be endan- 
gered by it. 

[According to Letheby (" Lectures on Food "), " Dr. Livingstone 
tells us that when the flesh of animals affected with pleuro-pneumonia 
is eaten in South Africa by either natives or Europeans, it invariably 
produces malignant carbuncle. He says, indeed, that the effects of 
this poison were often experienced by the missionaries who had eaten 
the meat, even when the presence of the disease was scarcely per- 
ceptible. . . . The virus, he says, is neither destroyed by boiling 
nor by roasting, and of this fact he had innumerable instances. 
Now it is a remarkable circumstance that ever since the importation 
of this disease (pleuro-pneumonia) into England from Holland in 
1842, the annual number of deaths from carbuncle, phlegmon, and 
boils has been gradually increasing."] 

Canine madness (hydrophobia, lyssa), which is transferred from 
animals to men, is better known and more frequent than either of the 
above diseases. From unknown reasons, the disease appears to de- 
velop primarily only in dogs; but from the bite of this animal, and the 
entrance of its saliva into the wound, it may be transferred to any 
animal, and apparently the poison does not decrease by inoculation, 
but is always propagated with equal power. For instance, a mad dog 
bites a cat ; the disease develops in the latter, and she bites a man ; 
an animal being inoculated with the saliva or blood of the man will 
have the disease. 

The symptoms in the dog are described by the veterinarians as 
follows : We distinguish a raving and a quiet madness ; previous to 
both of them the dog is downcast and eats little. After this state 
has lasted about a week the raving madness begins; the dog runs 
about in an objectless, unsteady way, apparently urged by some in- 
ward anxiety ; if irritated, he bites at any thing coming in his way ; 
the mouth is dry ; he tries to drink, but soon runs from the water without 
taking it ; he emaciates, he totters, then his hind-legs become par- 
alyzed, his barking changes to a kind of howl, twitchings come on, 
and in three or four days are followed by death. In the still mad- 
ness, paralysis of the muscles of the lower jaw occurs early, render- 
ing biting and eating impossible. The other symptoms are the same 
as just described. Some do not consider these two forms of the 
disease as distinct, but as different stages, only lasting a longer or 
shorter time. On autopsy of animals dying from this disease, we 
usually find the gastric and intestinal mucous membrane much red- 
dened ; this is probably merely due to the various foreign bodies 
that the dog has swallowed. Beyond this, we find nothing abnor- 






HYDROPHOBIA. 401 

mal, especially in the brain and spinal medulla; but we must add that 
hitherto no microscopical examinations of these parts have been 
made, while it is very probable that, in cases where paralysis very 
evidently occurs, there is degeneration of the spinal medulla, although 
otherwise the predominant character of the disease is humoral. 

As regards the transfer of hydrophobic poison to man, it is a relief 
to know that all those bitten do not become sick, but that only about 
one out of twenty cases bitten is attacked. Usually the bite heals 
readily ; more rarely it suppurates a long time, which is to be regarded 
as very favorable ; the local reaction is never of such a nature as to' 
threaten danger, and in this respect the hydrophobic poison differs 
essentially from the animal poisons heretofore mentioned ; it is not a 
phlogogenous poison. The outbreak of the disease rarely occurs in 
less than six weeks after the bite, frequently even later ; a case has 
recently been observed where the disease first appeared after six 
months. Older writers give a still longer period of incubation; there 
is a popular belief that the figure 9 plays an important role y it is 
said that the disease appears the 9th day, the 9th week, or the 9 th 
month after the bite, and that before the end of the 9th year there is 
no security that the disease will not appear. This is certainly a fable, 
which is readily explained by the fact that the long duration of the 
incubation is very strange, and has given rise to the various stories. 
Where the poison remains hidden during this long time, whether in 
the cicatrix, in the next lymphatic glands, or in the blood, is entirely 
unknown. In a few cases only it has been observed that, shortly 
before the outbreak of the disease, the patient had noticed a slight 
redness of the cicatrix ; then the first symptoms were great irritability, 
excitement, and restlessness, and in rare cases, even in this stage, 
there were spasms on attempting to swallow. The irritability con- 
stantly increases ; the light, every noise or draught, pains these un- 
fortunate patients, and may excite general spasms and the pains on 
swallowing. Now, very gradually, the fear of water appears ; the 
patients suffer from unspeakable thirst, and as soon as they see any 
liquid they are attacked by horrible anxiety and spasms ; occasionally, 
attacks of deep spasmodic inspiration follow; the patient cannot sleep, 
and is in constant dread of the least sound, as any thing excites the 
convulsions, which finally affect the whole body, and then lead to 
actual madness, with the appearance of most fearful anxiety. But, 
on the whole, the patients may be readily calmed by quiet and by 
speaking to them, and become either perfectly resigned or melancholy. 
Occasionally they warn those about them not to come too near or they 
may bite them, but they are not at all malignant, as they were for- 
merly described. Great salivation and foaming from the mouth do 
26 



402 TKAUMATIC AND INFLAMMATORY DISEASES, ETC. 

not begin till toward the end ; in some cases death is preceded by the 
severest tetanic spasms; others die after the convulsions and the fear 
of water have completely ceased, and when the patient and surgeon 
have been led into vain hopes. Unfortunately, pathological anatomy 
gives us no explanation of this wonderful and fearful disease. There 
can be no doubt that the spinal medulla is affected, but it has not yet 
been determined whether the nerve-substance itself is diseased. 

As regards the prognosis, in those patients where the disease has 
broken out, there is no hope. It may be considered proper, in all 
cases, to cauterize or burn out the bites of mad animals, and to keep 
them suppurating a long time; at least this is the only rational treat- 
ment. It cannot be certainly decided from past observations whether 
excision of such a cicatrix can be useful after the disease has already 
broken out ; it would at all events be a rational treatment. In the 
developed disease, almost all the powerful remedies in the materia 
medica and in surgery have been tried ; all the narcotics have been 
used in large and small doses ; opium and belladonna especially, 
used in almost poisonous doses, and the artificial benumbing of the 
patient, have at least alleviated their sufferings, if they have done 
no other good. The limb containing the cicatrix has been amputated 
in vain. In one patient, Dieffenbach tried transfusion in vain. 
Where there is dread of water, some fluid may be introduced through 
a tube ; the patients are most comfortable when at absolute rest in 
a half -darkened room ; in combating the convulsions, chloroform 
narcosis has repeatedly proved most serviceable, and patients who 
have once become acquainted with this remedy beg for it again. 
But this comprises the little that we can do for these unfortunates. 



The three diseases last mentioned enter so much into the domain 
of veterinary surgery, sanitary regulations, and internal medicine, that 
I could here give you only a slight sketch of them. You will find 
more accurate information on the subject in 'Virchow's special pa- 
thology, Bd. II., Section Zoonosen, where the special literature is 
also given. In the surgery published by V. Pitha and myself you will 
also find (vol. i., part ii.) an exhaustive section on the Zoonoses. 



CHAPTER XIV. 

CHRONIC INFLAMMATION, ESPECIALLY OF THE 
SOFT PARTS, 



LECTURE XXVIII. 

Anatomy : 1. Thickening, Hypertrophy ; 2. Hypersecretion ; 3. Suppuration, Cold 
Abscesses, Congestive Abscesses, Fistula, Ulceration. — Eesults of Chronic Inflam- 
mation. — General Symptomatology. — Course. 

Gentlemen : Having thus far attended almost exclusively to acute 
affections, we now come to the chronic, and first of all to chronic in- 
flammation. 

In chronic inflammation also, as in acute, there are chemical and 
morphological changes and nutritive disturbances of tissue ; they are 
followed by softening and solution, or molecular disintegration, or 
extensive slowly-developing necrosis of tissue. To these processes 
are added dilatation of the vessels, exudation, and formation of new 
tissue. This combination may vary ; chronic inflammation leads to very 
complicated appearances, according as one or other stage of the pro- 
cess remains more or less permanent, and according as there is dis- 
integration, softening, or hardening of the tissue implicated, and as to 
the varied fate of the inflammatory neoplasia. Etiologieally, the con- 
ditions in chronic inflammation are much more complicated ; for there 
it is not merely a question about an irritation only once, as an injury 
or a burn, and their sequences, but we have, 1, to explain the cause 
of the inflammation ; and, 2, why it assumes a chronic character. I 
shall first explain to you what anatomical changes take place in the 
tissues during chronic inflammation, in doing which, just as we did in 
acute inflammation, we shall here take the connective- tissue as the 
ordinary seat of the disease. Besides the distention and multiplication 
of the capillary vessels by formation of loops in acute inflammation, 
we found serous and plastic infiltration of the tissue to be the essen- 
tial anatomical appearances. In chronic inflammation, distention of 



404 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

the capillary vessels, or fluxion, is a less prominent symptom, while 
the new formation of tissue and serous infiltration seem to play a 
more important role. The cell-infiltration of the tissue takes place in 
few cases, as it does in acute inflammation ; but the individual cells 
often attain a rather more complete development. In this process of 
development the intercellular tissue changes ; the connective-tissue 
filaments lose their tough filamentary consistency, the distensibility 
and elasticity of the subcutaneous tissue are impaired, and the conse- 
quence, as regards the coarser, palpable, and visible consequences, is 
that the tissue becomes more swollen and fatty, and less movable 
than normal. This is the first stage of every chronic inflammation. 
The course may vary as follows : 

1. The tissue remains permanently in this state of serous, and, to 
some extent, plastic firm infiltration ; skin and subcutaneous cellular 
tissue, articular capsule, tendons, ligaments, fasciae — in short, all these 
connective-tissue constituents of the body which are in the above 
state — on section present a rather homogeneous, fatty appearance. 
In diseases of the joints and their vicinity we see this most frequently, 
and, as this swelling of the joint goes on without any reddening of the 
skin, it was formerly called tumor albus, a name which tells nothing 
of the nature of the process, but which, limited to certain forms of 
joint-disease, is practically serviceable. You may readily imagine that 
tissue which has been little altered may return from this stage of the 
disease to its normal state. The infiltrated serum is reabsorbed ; the 
cells, which have newly entered the tissue or have newly formed there, 
partly become connective-tissue corpuscles, and are partly destroyed ; 
the connective tissue itself returns to its former condition, and, if the 
state of affairs be not exactly as it was, it is nearly so ; occasionally 
a state of cicatricial thickening remains ; during the development of 
the chronic inflammation there may also have been small extravasa- 
tions or escapes of red blood-cells through the walls of the vessels, 
from the increased pressure (according to Cohnheim) ; these change 
to a brownish-red pigment, which, when present in quantities, gives a 
yellowish or grayish color to the tissue that has been diseased. As a 
result of the continued excess of nutrient material, which sometimes 
flows to the diseased part in chronic inflammation, the tissue-elements 
may become larger and thicker ; the whole tissue may increase ; it 
passes into a state of simple hypertrophy. But sometimes the plastic 
(cellular) infiltration in chronic inflammation may attain a particularly 
high grade ; from the infiltrated young cells new connective tissue 
forms in the old, so that the skin may be thickened to three or four 
times the normal extent ; this deposit of new tissue of similar forma- 
tion, in the old, is called hyperplasia by the pathological anatomists. 



COURSE OF CHRONIC INFLAMMATION. 405 

When the thickening of the skin assumes a nodular form, it is usually 
termed elephantiasis in the most general sense of the term. Such 
hypertrophies and hyperplasias of the connective tissue, which may 
form in the course of a chronic inflammation, hardly ever recede en- 
tirely, but often remain in the same state, even when their causes 
have been removed. 

2. If you imagine the chronic inflammation, so far as you at 
present know it, transferred to a mucous or serous membrane, you 
will acknowledge that the secretion cannot remain normal during the 
pathological changes which affect the tissue of these membranes. 
Usually it increases, there is hypersecretion y chronic inflammation of 
a synovial or mucous membrane may evince itself cteefly by this 
hypersecretion. 

Chronic catarrh of the mucous membranes may affect chiefly the 
epithelial or the connective-tissue layer or the glands of the mem- 
brane ; in many cases all three suffer to an equal extent. The same is 
the case in the synovial membrane of the joints ; some forms of chronic 
articular inflammation are chiefly noticeable from a very free secretion 
of a watery synovia ; in others, there is more thickening of the syno- 
vial membrane, and but little increase of secretion. 

3. Chronic inflammation may also be accompanied by suppuration, 
and its finer changes are just as in the acute disease, except that 
every thing is slower. For instance, suppose there is at some part of 
the body a collection of wandering cells with a formation of fluid 
intercellular substance; at the same time, of course, the tissue in 
which these cells are infiltrated dies, as always happens in circum- 
scribed cell-proliferations. The tissue surrounding the spot first dis- 
eased is gradually infiltrated with cells ; and it also goes on to form 
fluid cellular tissue with the character of pus ; the infiltrated tissue is 
the more disposed to suppurate and break down when its vessels are 
little developed and do not supply sufficient qualitative and quantitative 
nutrient material to maintain the further development of the exces- 
sive cells. In abscess, a circumscribed cavity containing pus is thus 
formed, its walls are constantly being changed to pus, suppurating. 
All this takes place very gradually, and frequently the symptoms 
usually appearing in inflammation are wanting ; often there is no pain, 
redness, or elevation of temperature, in the affected part, and usually 
there is no fever. Hence this variety of abscess, which comes on 
chronically, is called cold abscess y for this chronic suppuration we use 
the term ulceration (" verschwarung "). We might also term the whole 
cavity containing pus a hollow ulcer (" hohlgeschwur ") ; but in 
common language this expression is applied chiefly to small cavities, 
while larger, slowly-forming ones are called cold abscesses. If you 



406 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

examine the pus from such an abscess microscopically, you will find it 
rich in fine molecules, but rather poor in well-developed pus-cells* 
This is because the pus has long been enclosed in the body, and is 
changed by disintegration of the pus-cells to molecules, and by chem- 
ical decomposition ; by the latter rich excretions of fat, especially of 
cholesterine crystals, are formed. The appearance of the pus to the 
naked eye is also changed by these metamorphoses, for it is usually 
thinner and clearer than in the acute disease, and has a disagreeable 
odor like fatty acids, and may contain fibrinous flocculi and shreds of 
necrosed tissue. Sometimes it is months or years before the suppu- 
ration of the walls of a cold abscess has gone so far as to cause per- 
foration of the skin. In some cases it even happened that such an 
abscess has existed for years, that the ulceration of its walls finally stops, 
and the latter are transformed to a cicatricial capsule, and the pus is 
thus completely encapsulated. If we have opportunity to examine 
such an abscess, we find in it an emulsion-like fluid, occasionally con- 
taing crystalline fat, and sometimes without a trace of pus-cells, so 
that, from the appearances, we could hardly infer that the sac in 
question had been an abscess, if the whole previous course did not 
show it. Much more rarely, in the course of time, when the abscess 
has ceased to grow, there is reabsorption of the fluid, a cheesy pulp 
being left. If the abscess has perforated outwardly, the pus is evacu- 
ated, and, under otherwise favorable circumstances, there may be 
healing, as we shall soon describe. But, for this to occur, the ulcera- 
tion on the inner wall of the abscess must cease, which generally only 
occurs when there is a sufficient development of vessels in the walls 
of the abscess ; under their influence the inner surface of the abscess 
changes to a vigorous granulation-tissue, and then it condenses and 
atrophies to cicatricial tissue, and the opposite walls of the cavity 
unite, as in the healing of acute or hot abscesses ; the pus escaping 
from the opened cavity grows less, and finally ceases altogether. 
Some time subsequently we may still feel the subcutaneous cicatrix 
of the abscess as a callous thickening ; but, in the course of time, this 
also passes off, and the abscess-cicatrix again assumes the characteris- 
tics of ordinary connective tissue. I will now make you acquainted 
with a technical name used for those abscesses which do not originate 
at the points where first seen, but which have moved partly from 
sinking of the pus, partly from the ulceration having progressed 
chiefly in one direction. For instance, there may be suppuration along 
the anterior part of the spinal column, which, following the loose 
cellular connective tissue behind the peritonaeum, and travelling along 
the sheath of the psoas muscle, finally appears as an abscess beneath 
Poupart's ligament. These and similar abscesses are called conges* 



COURSE OF CHRONIC INFLAMMATION. 407 

five abscesses. The mode of healing above indicated does not take 
place with desirable rapidity, but, unfortunately, the general and local 
conditions are occasionally of such a nature that, after the evacuation 
of the pus, acute inflammation, with fever, attacks the abscess, and 
pyaemia or febrile marasmus comes on, or else, in spite of the evacua- 
tion of the pus, the chronic ulceration goes on slowly but steadily in 
the walls of the cavity. In such cases the openings of these large, 
often deeply-seated cavities continually pour out a thin, bad pus ; the 
openings of such abscesses, whether of small or large diameters, are 
called fistvlce. 

You may also imagine the above process of suppuration or ulcera- 
tion as transferred to a surface or membrane ; then we should have a 
flat or open ulcer, but, as this is an object of special and great prac- 
tical importance, we must treat of it in an independent chapter. 

4. Chronic inflammation may take another course very like sup- 
puration, that is, caseous degeneration of the inflammatory neoplasia. 
Imagine, again, a great collection of young cells, and suppose, further, 
that in the centre this group undergoes molecular disintegration, and 
forms a cheesy pulp without separation of fluid intercellular substance. 
Plastic infiltration goes on slowly in the periphery of the caseous spot, 
by the collection of wandering cells, but the infiltrated tissue also 
passes into the caseous metamorphosis, and thus the central focus 
constantly increases. Here, also, as in suppuration, the failure of a 
vascularization keeping pace with the cell-formation is the local cause 
of the disintegration ; here is a form of ulceration that may be termed 
" caseous ulceration " (a vascular, dry necrosis). When these yellow 
spots are found in the cadaver, it is often supposed that they corre- 
spond to a dried collection of pus, but this is not true, or, at least, 
very rarely so ; most of these cheesy collections were from the first in 
miniature what they now are in gross, and were never fluid pus. It 
may very readily be proved experimentally that these caseous spots 
may proceed directly from the inflammatory new formation without 
suppuration. If, for instance, by introducing a foreign body (as a se- 
ton) into the subcutaneous tissue of a rabbit, you excite continued 
inflammation, in the course of a few days a yellow, cheesy mass forms 
around the foreign body ; it is true this is the same for the rabbit as 
pus is for a man, but it was never fluid pus. There are also morbid 
processes in man in which, during chronic inflammation, this caseous 
transformation occurs instead of suppuration. In man, the further 
fate of these foci varies. If the process take place in a part not too 
far below the surface, it may, by advancing from within outward, cause 
perforation ; the pulp is evacuated, and the cavity may gradually 
close as a cold abscess does. When this is the termination, it is usu- 



408 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

ally accompanied by secondary softening of the mass, which is at first 
dry and cheesy, and this fluid pulp under the microscope is found to 
be composed almost entirely of molecular granules, some fat, shreds 
of tissue, and half-atrophied cells. The above process may be seen 
especially often in chronic inflammation of the lymphatic glands ; but 
in them the spontaneous throwing off of the caseous deposit takes 
place very slowly, hence these fistulas of lymphatic glands often re- 
main stationary for months or years. 

Another termination is for the caseous deposit to attain only a 
slight extent, then to atrophy entirely, and to take up such a quantity 
of lime-salts as to finally form a chalky concrement, which is concen- 
trically enclosed by a cicatrix. But, as was stated, this only occurs 
in small caseous deposits. 

5. There is still another form of chronic inflammation, which is ac- 
companied by the deposit of a peculiar substance, the so-called larda- 
ceous or amyloid, from the blood. But I shall not enter into this 
subject further, for this form of disease occurs chiefly in the internal 
organs, and hence has only an indirect interest for us. 

First, as regards the results of chronic inflammation in a purely 
histological view, they vary. The cell-infiltration and the neoplastic 
process goes on chiefly in the connective tissue, and after its termina- 
tion the final result is either a restitutio ad integrum or a cicatrix after 
the part has been destroyed by ulceration. When this process attacks 
muscles or nerves, the tissues suffer severely secondarily. The con- 
tractile substance in the muscle, as well as the axis-cylinder and 
medullary sheath of the nerve-filament, is not unfrequently destroyed by 
molecular disintegration or fatty degeneration, due to the disturbance 
of nutrition. Hence atrophy of the muscles and paralysis may result 
from chronic inflammation. How far the regenerative power of muscles 
and nerves goes under such circumstances is not decided. Molecular 
destruction and fatty degeneration may also occur without inflamma- 
tion of the connective tissue enveloping the muscles and nerves. But 
I do not think we are justified in terming such a process of fatty 
disintegration of the protoplasm inflammation of the muscles and 
nerves, as has been done by Virchow in the muscles, at least, although 
it must be acknowledged that, in the great majority of cases, the ap- 
pearance of fat-granules in the protoplasm may be regarded as the 
first expression of pathological (but not always retrogressive) pro- 
cesses in the body of the cell (Strieker). The fatty disintegration of 
a tissue may be the result of inflammation, or may even accompany 
it ; but to seek in it the nature of the inflammation, and to regard the 
latter as a disturber of nutrition to so wide an extent, does not seem 
to render it more comprehensible or of practical benefit. We regard 



SYMPTOMS OF CHRONIC INFLAMMATION. 409 

every inflammation as accompanied by infiltration of the tissue with 
cells. 

After these general anatomical considerations, let us briefly run 
through the symptoms of chronic inflammation. They are the same 
as in acute inflammation, only they often come in a different order 
and in other combinations, and are usually less intense. 

Swelling of the diseased part is usually the first noticeable symp- 
tom ; it depends partly on serous, partly on plastic infiltration. The 
parts feel doughy, and at first quite firm ; if an abscess forms, as may 
happen in the course of weeks or months, fluctuation gradually be- 
comes more evident. We shall only perceive redness of the inflamed 
parts, when they lie on the surface, for, as the vessels are occasionally 
but little distended, it is not very intense or extensive. We may 
readily detect chronic inflammation of the nasal mucous membrane, or 
of the conjunctiva, by the swelling, redness, and increased secretion. 
Chronically inflamed skin gradually assumes a bluish or brownish-red 
color. But, if the inflamed parts lie deep, the skin is not discolored, 
and only becomes red when the deep chronic inflammation finally im- 
plicates the skin, as in the perforation of cold abscesses. Pain is one 
of the symptoms of chronic inflammation that varies most ; in some 
very tedious cases it is entirely absent, but in other cases may be very 
severe, having a tearing, boring character, sometimes appearing spon- 
taneously, at others only on pressure, or on merely touching the parts. 
The funcUonal disturbance depends essentially on the pain and on the 
anatomical changes in the parts. Seat, the temperature appearing 
elevated when the hand is laid on the part, is not usually marked, or 
is very slight. 

Fever is a symptom not necessarily pertaining to chronic inflam- 
mation ; it usually appears only when the inflammation assumes an 
acute character, as not unfrequently occurs during its course, especially 
when the body has been much debilitated by long-continued suppura- 
tion. Then we have the so-called hectic fever, a febris continua, or 
simply remittent, with great differences in the morning and evening 
temperature of the body, a fever with steep curves. According to my 
idea, this hectic or consumptive fever results from continued absorp- 
tion of the products of inflammation, especially of disintegration ; 
hence it is most frequent and most intense from rapid breaking down 
of the inner walls of large abscesses, and in rapid progressive ulcera- 
tion. This fever often runs its course with rapid emaciation, night- 
sweats, and diarrhoea. Few patients stand such chronic suppurative 
fever long ; though I observed a boy fourteen years old, with a fistula 
remaining after resection of the head of the femur and general larda- 



410 



CHRONIC INFLAMMATION OF THE SOFT PARTS. 



ceous disease, a whole year, during which he had a continued febris 
remittens ; he finally died from general dropsy. 

The course of chronic inflammation may be classed under two gen- 
eral heads. In the first case, even the commencement of the disease 
is indistinct, and can scarcely be stated with any certainty by the pa- 
tient. Sometimes it is a swelling, a moderate pain, or a slight dis- 
turbance of function that has called attention to a morbid state. Cases 
which have begun so insidiously usually maintain this character in 
their further course. In other cases, the chronic inflammation is a 
remnant of an acute process ; the chronic course is interrupted from 
time to time by acute attacks, with fever. We can say least that is 
definite about the duration of chronic inflammation in general, as 
this above all things depends on the exciting causes, to which we 
shall soon come. I only entreat you to bear in mind that chronic 
inflammation, like the acute, has a tendency to terminate, to have a 
typical end, for the new formation never goes beyond the develop- 
ment of certain characteristic metamorphoses of tissue, which lead 
to development of connective tissue, or of a cicatrix in some way, 
unless the diseased tissue is destroyed by disintegration. Why it is 
important to remember this will be clearer to you when we treat of 
the limitation of other new formations, such as actual tumors. Of 
course the new formation attains no typical end when its causes can- 
not be removed, or do not spontaneously disappear, and when organs 
are destroyed that are necessary to life, or when the strength is ex- 
hausted by suppuration. 



LECTURE XXIX. 



General Etiology of Chronic Inflammation. — External Continued Irritation.— Causes in 
the Body.— Empirical Idea of Diathesis and Dyscrasia.— General Symptomatology 
and Treatment of Morbid Diatheses and Dyscrasia?. 1. The Lymphatic Diathesis 
(Scrofula) ; 2. Tuberculous Dyscrasia (Tuberculosis) ; 3. The Arthritic Diathesis ; 
4. The Scorbutic Dyscrasia ; 5. Syphilitic Dyscrasia. 

To-day we come to one of the most important parts, not only of 
this section, but of all medicine, that is, to the causes of chronic in- 
flammation. We saw how acute inflammation resulted from an irri- 
tant acting once, and varied according to the anatomical condition of 
the irritated part, and the nature and extent of the irritation, but that 
it ran a relatively short and typical course. Now we have to deal 
with inflammations that last several months or years ; here there 
must be a continued cause, a long-acting irritation, or some abnormal 
reaction to simple irritation. These continued irritations may be of 



CAUSES OF CHRONIC INFLAMMATION. 41 1 

a purely local character ; let us consider them for a moment. When 
small animals, like the itch-insect, take up their abode in the skin, as 
they dig burrows like a badger's in the superficial layers of the cutis, 
lay eggs, and there lead their laborious life, they cause constant irri- 
tation of the skin ; to this is added the scratching, and a chronic in- 
flammation of the skin is thus caused and kept up. If spores of 
fungus locate in the epidermis, and there begin to grow and to mul- 
tiply to millions of small vegetable organisms, the skin will be placed 
in a state of continued irritation by these little foreigners ; and va- 
rious chronic cutaneous eruptions will result, such as favus, herpes 
tonsurans, pityriasis versicolor, etc. If a pressure or friction act 
moderately but continuously on the skin, it also is a chronic irritation, 
which is particularly apt to induce thickening of the part of skin af- 
fected. The callous spots on the heel and many corns are the result 
of the continued friction and pressure induced by our modern foot- 
coverings. In the same way the workman who uses axe and hammer 
a great deal has callosities in the hand, the shoemaker has them on 
the outer side of the little finger and hand where he daily draws on 
the pack-thread, etc. [We see the same thing much more markedly 
on the side of the left thumb and forefinger in plasterers, from hold- 
ing their plaster-board ; and at the upper and posterior part of the 
front leg of some horses, from lying on their iron shoes.] Sometimes 
foreign bodies in the tissue keep up a continued chronic irritation in 
the surrounding parts. Continued or often-repeated chemical irrita- 
tion of the tissue may also induce chronic inflammation ; for instance, 
chronic gastric catarrh may be caused by the repeated use of schnaps 
or strong liquors. Continued stagnation of blood and lymph, as 
well as their coagulation in the vessels, first induces hyperplasia of 
the walls of the vessels, and of the parts immediately around them, 
distention and tortuosity of the vessels, and thickening of the tissue ; 
the skin of the leg is particularly exposed to this disease when there 
is any continued opposition to the escape of venous blood from the 
extremity. 

When we have to treat chronic inflammations that may be traced 
to such external continued irritations, of which many more illustra- 
tions might be given, the results will be favorable. We get rid of 
the animal or vegetable parasites, the foreign bodies, the continued 
pressure, chemical influences, etc., and the chronic inflammation will 
disappear spontaneously. So far we have supposed a local irritation 
acting continuously on healthy tissue ; if you suppose a tolerably se- 
vere irritation acting once on a tissue already diseased, you cannot 
expect the conditions to prove as favorable as in a simple traumatic 
inflammation of healthy tissue ; but it is probable that the results, 



412 



CHRONIC INFLAMMATION OF THE SOFT PARTS. 



even of the single irritation, will be different, possibly more continued, 
because the conditions in the tissue will not be so favorable for typical 
removal of the disturbance. Suppose a portion of skin already suf- 
fering from chronic inflammation to be superficially contused, this sin- 
gle irritation may induce chronic suppuration, or even progressive ul- 
ceration, which, under normal conditions, would quickly have gone on 
to new formation of epidermis and healing. 

The cases where we find such purely local causes for the origin 
and continuance of chronic inflammation are comparatively rare. In 
the great majority of cases the cause is not so evident; the case 
must be watched and tried in various ways before we can obtain any 
clew to the etiology of most chronic inflammations and diseases. We 
have not here mentioned miasm and contagion from the domain of 
general etiology ; and we may leave them out of the question, for 
there is nothing to show that chronic inflammation may arise from a 
single action of contagion or miasm. It is true there are chronic 
malarial diseases, such as intermittents, etc. ; but there the cause of 
injury acts continuously, and not unfrequently the disease can only be 
cured by removing the patient from the miasmatic atmosphere ; hence 
this case corresponds to a continued external irritation. The same is 
true of repeatedly catching cold, where the new attack affects the 
body already diseased, and thus induces chronicity of the process. 
But all this does not suffice for the etiology of chronic inflammations; 
we must also look for the causes in certain congenital or developed 
conditions of the whole body. Let us hear what experience teaches 
on this subject. 

On careful observation we first notice that certain forms of chronic 
inflammation constantly recur in certain organs and certain parts of 
the body ; that at the same time they show themselves chiefly at cer- 
tain ages and in persons presenting some similarities in their external 
conditions. Thus we see children of the same class, who are pecu- 
liarly disposed to chronic swelling and suppuration of the lymphatic 
glands, joints, and bones, other persons who are chiefly affected by 
insidious inflammation of the lungs, others who are particularly liable 
to colds and have pains in the different muscles and joints. We also 
see that such persons, who are constantly being attacked in the same 
way, transfer their individual pathological peculiarities to their de- 
scendants ; that those leaving such legacies have in their turn received 
them from their fathers or mothers. To obtain some clear idea of 
individual morbid predispositions in this chaos, persons predisposed 
to certain chronic diseases were divided into groups ; thus, in a purely 
empirical manner, men were divided, according to morbid dispositions 
or diatheses, into lymphatic, scrofulous, tuberculous, rheumatic, etc. ; 



CAUSES OF CHRONIC INFLAMMATION. 413 

terms which at first merely meant that the scrofulous, for instance, 
were especially predisposed to glandular diseases ; the tuberculous to 
the development of ulcerating nodules, etc. Subsequently this group- 
ing was carried further, and it was concluded that a certain morbid 
condition of the physiological processes of the entire body must lie at 
the root of such predispositions. A morbid material, or essence, a 
materia peccans, was supposed to exist in the body ; the most natural 
bearer of this was the blood, for this passed through the entire body, 
and its condition certainly gave a measure for the more or less normal 
or pathological condition of the entire body. The word dyscrasia (a 
bad mixture) indicated such a pathological condition of the blood ; 
hence a scrofulous, tuberculous, etc., dyscrasia were spoken of. It is, 
however, a strange idea to burden the blood alone with the patho- 
logical changes of the whole body, and assume, as it were, that infec- 
tion of the whole body resulted from it. This could only be acknowl- 
edged in cases where an abnormal material was introduced into the 
blood from without, as we have seen to be the case in poisoned 
wounds. But this is not the case in the dyscrasiae under consideration, 
or at least it is only partially so ; but the morbid dispositions develop 
in the body itself from causes little known, if they be not handed 
down as an inheritance from the parents. The blood is no more 
absolutely stable than any other tissue of the body ; it is constantly 
being renewed, partly used up and again renewed, etc. ; we do not 
certainly know the source for the renewal of the blood-corpuscles ; 
you know from physiology that the serum of the blood is constantly 
being regenerated from the lymph, and this again from the chyle- 
vessels of the intestines, and you also know that fluid constituents 
from the blood are excreted by kidneys, lungs, and skin. How little 
we know of these things, and how complicated even these little affairs 
are ! I lead you to this consideration to add that normal blood can 
only form from a healthy body, and the reverse ; hence that we 
cannot physiologically speak of a one-sided disease of the blood. But 
there would be no use waging war against and trying to root out the 
words dyscrasia and diathesis, now firmly embedded in medical lan- 
guage. It would do science no harm to use them forever with the 
above meaning ; we must have a name for these things, for they are 
not myths, but are facts that have been observed for centuries, although 
their significance has varied greatly. We may go too far in classify- 
ing persons in this matter, if we ascribe to every one a pathological 
diathesis, or try to place every patient in one of the chief divisions. 
Although there might theoretically be a certain amount of correctness 
in supposing that in our present state of cultivation there was no such 
thing as an absolutely healthy man, still, it would be very senseless 



414 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

to try to maintain this in practice. And you must not suppose that 
it is always so easy to class every patient in certain groups, just as 
plants are analyzed and their systems determined, for all classes of 
men may breed with each other ; moreover, some abnormally-formed 
individuals may become perfectly normal in the course of time, and 
the reverse ; thus a number of middle forms naturally result, which 
defy any classification. There are now, as there have at all times 
been, physicians who are too skeptical about the existence of a gen- 
eral morbid disposition to certain forms of disease, and only acknowl- 
edge local and partly only accidental irritations as causes. Such a 
hyperskeptical current ran through modern medicine a short time 
since, and was perfectly justified, for the crasis doctrine had become 
so luxuriant, that there was scarcely a variety of inflammation, scarcely 
a disease, in fact, which was not based on some specific crasis. Who- 
ever observes independently and carefully, and at the same time has 
the opportunity of seeing a variety of patients, will certainly arrive 
at the correct view in the course of time, and will neither throw him- 
self too unreservedly into the arms of the crasis theory, nor set aside, 
as illusions and deceptions, the experiences of centuries. It is a ques- 
tion whether it be of any practical value to use such terms as scrofu- 
lous or syphilitic inflammation, if it would not be better to regard 
the chronic inflammatory processes without any regard to their origin. 
The future will decide this question ; at present I deem it my duty as 
teacher to clear your views on these points as much as possible, and 
to place you in a position to be able to understand all your colleagues 
speaking on these subjects, no matter to what school they belong. 
But enough of this general explanation ; let us draw a brief sketch of 
the different diatheses and dyscrasiae : 

1. The lymphatic or scrofulous diathesis {scrofula). This tendency 
to disease exists chiefly during childhood, though more advanced ages 
are not free from it. Persons with this diathesis, especially children, 
are greatly disposed to chronic inflammatory swellings of the lym- 
phatic glands, even after inconsiderable irritations, to certain inflam- 
mations of the skin (eczema, impetigo), especially of the face and 
head, to catarrhal inflammations of the mucous membranes, especially 
of the conjunctiva, more rarely of the intestinal canal and respiratory 
organs, to chronic inflammations of the periosteum and of the synovial 
membranes of the joints. As regards the swelling of the lymphatic 
glands, especially of the submaxillary and occipital, it has been asserted 
that it is merely a result of irritation from dentition, or of the 
eczematous eruptions on the head, of the inflammations of the eye, 
ear, etc. ; this is partly correct, but even taking this view, that all 
swellings of the lymphatic glands are secondary, even then for the 



SCROFULA. 415 

glands to swell after dentition, for instance, there must be an abnor- 
mal irritability of the lymphatic system such as does not exist in all 
children ; moreover, such local irritations cannot always be found for 
the affections of the bronchial and mesenteric glands, which are almost 
as frequent. It is also a morbid state for the swellings of the 
lymphatic glands to last longer than the irritation, and even subse- 
quently to increase without apparent cause. It may be acknowledged 
that some of the above affections — for instance, part of the scrofulous 
diseases of the joints— are caused by injuries, contusions, etc. ; but the 
fact that they take a chronic and to some extent entirely peculiar, 
constant course, is due to abnormal condition of the tissue, which ab- 
normal condition is so spread over the entire body that it cannot be 
regarded as a purely local, but must be considered a universal condi- 
tion. Various attempts have been made to explain this local and gen- 
eral abnormity, especially to refer the " chronicity " to a continuance 
of the irritation, so as to escape the enigma of an organism reacting 
differently to one irritant from what it does to another. Hence it 
has been assumed that the matters formed by a chemical change in 
the tissues, from whatever cause, were not taken up by the lymph- 
and blood-vessels and removed from the diseased organ, but remained 
there and induced continued inflammatory irritation. I am far from 
denying that this takes place occasionally; but even if it were always 
true, the peculiarity just mentioned of this or that organ still remains 
abnormal in these persons. In short, we do not thus escape the fact 
that these persons differ from the majority either in certain tissues 
or in toto. Children fall times without number on knee, hip, or 
elbow, without any disease resulting, or else the effects pass off in a 
few days, even without treatment and when there has been consid- 
erable bruising, as shown by the extensive extravasation, swelling, 
and pain. But even after slight injuries some children have chronic 
inflammations of the joints ; these are exceptions; there is, however, 
no objection to regarding them as a peculiar pathological race. At- 
tempts have been made to diagnose the scrofulous diathesis from the 
general appearance and condition of the child. The following is the 
picture usually drawn of a scrofulous child : blond hair, blue eyes, 
very white skin with thick cellular membrane, thick lips, pot-belly, 
voracious appetite, and tendency to constipation {torpid scrofula). 
In practice you will meet some of the originals of this portrait, but 
you will see many other cases not at all like it, which nevertheless 
suffer from typical scrofula. I do not attach much importance to 
these external symptoms. In regard to the course and terminations 
of chronic inflammation in scrofulous children, we may make the fol- 
lowing remarks : In a few cases the chronic inflammatory swelling 



436 



CHRONIC INFLAMMATION OF THE SOFT PARTS. 



sooner or later subsides entirely, and the parts become perfectly nor- 
mal. The course with suppuration is the most frequent, and accord- 
ing to the special nature of the case this may be quite acute, as it is 
in inflammation of the submaxillary glands and in inflammations of 
the joints. Often the disease remains chronic for years ; abscesses, 
fistuke, ulcers, etc., form. Early suppuration occurs, especially in 
somewhat emaciated, debilitated, badly-nourished children, who are 
very liable to fever (erethitie scrofula), and its prognosis is very bad. 
The termination of the inflammation in caseous degeneration is not 
rare ; it is particularly frequent in the lymphatic glands ; of course it 
must have a very bad effect on the general nutrition, when the mesen- 
teric glands are degenerated in this way, and the chyle-ducts thus 
mostly obstructed ; incurable atrophy of the entire body may thus be 
induced. The lymphatic diathesis is in most cases congenital, and is 
transmitted from generation to generation ; but it may also be devel- 
oped by improper modes of life. Among the most injurious causes 
are given : chief or exclusive diet of potatoes, flour, or sour bread ; 
unhealthy, damp dwellings ; lack of cleanliness, fresh air, etc. It is 
indeed difficult to prove if all this be correct ; at all events, if the 
above causes always induced scrofula, it would be much more frequent 
than it now is among the poor. 

To state in a few words what is at present understood by a lymphat- 
ic constitution or scrofula, it may be considered — 1, as a disposition 
to chronic inflammation of the skin, bones, and joints, in which the 
inflammation may lead to development of granulations, of pus, and 
to caseous degeneration ; 2, as existing when swellings of the lym- 
phatic glands, even when induced by temporary irritation, continue 
long in the same state, or even increase without new peripheral irri- 
tation. 

We shall here pass at once to the treatment of scrofula in general. 
First of all, the diet should be regulated ; good animal food, eggs, and 
milk, well-baked wheaten bread, occasional baths, residence in fresh, 
healthy air, a hardening mode of life, are the most important reme- 
dies, but from the circumstances they are often the most difficult to 
employ ; in prescribing the diet, special attention must often be paid 
to the individual case, especially as to whether there is a tendency to 
lardaceous disease or atrophy, whether the digestive organs are nor- 
mal, or were ruined in youth by improper diet. As the disease is 
very common among the poor (without the rich being free from it, 
however), these dietetic and hygienic rules are particularly difficult to 
follow. The number of internal anti-scrofulous remedies is very great ; 
the object is not, as was formerly supposed, to introduce a specific 
remedy as an antidote to some unknown poison circulating in the 






SCROFULA. 417 

blood, for the latter does not exist ; but the treatment should be purely 
symptomatic, and usually general. From the above, you see that 
scrofula is not a materia peccans in the blood, but only a debility of 
the organization in some direction, a more or less intense predisposi- 
tion to peculiar forms of disease. This is a decided difference from, 
and an advance beyond, the old view of the disease. From my ex- 
planation you may also understand those recent skeptics who think 
that all chronic inflammations in children are of similar origin, and 
that it is consequently unnecessary in each case of chronic inflamma- 
tion of the lymphatic glands, or in articular inflammation, to add that 
it is scrofulous or depends on a lymphatic diathesis. Possibly these 
expressions may disappear in the course of time, as they will be ren- 
dered unnecessary by greater clearness of ideas, but it is not correct 
to say that all chronic inflammations in children have the same origin, 
for some of them may be due to hereditary or developed syphilis; and 
in adults there are many other constitutional predispositions besides 
those that have hitherto been termed scrofulous or tuberculous, and 
which consist in the predisposition to chronic inflammations ending in 
suppuration, caseous degeneration, and ulceration. It seems to me 
that there can be no doubt that these processes are, to a certain ex- 
tent, opposed to other forms of chronic inflammation — for instance, 
to those depending on interstitial proliferation of connective tissue 
(cirrhosis of the liver, morbus Brightii, gray degeneration of the 
medulla spinalis, etc.). 

Many things have been tried to improve the lymphatic diathesis. 
Formerly purgatives were occasionally given, and in England particu- 
larly small doses of mercury were administered ; this is well suited to 
fat scrofulous children ; burnt sponge, folia juglandis regiae, herba 
jacea, acorn-coffee, and bitter medicines, were recommended, and are 
still used. At present, cod-liver oil is most used as an anti-scrofuletic, 
as it is not only considered to have a specific action against the scrofu- 
lous diathesis, but is very properly prized as exceedingly nutritious, 
and hence is especially used in emaciated scrofulous children ; in fat 
children it might even prove injurious. Some of the preparations of 
iodine act very well in scrofula ; but they should be employed care- 
fully, and in fat rather than in atrophic children ; iodide of iron is best 
in pale fat children, with fungous inflammations of the joints. The 
easily-digested preparations of iron are very valuable remedies in 
scrofula patients with anaemia. Salt-water baths also act beneficially ; 
these may either be used at the springs, in Germany, for instance, at 
Kreuznach, Rheme,Wittekind, Coblenz, Tolz, Reichenhall ; in Austria, 
at Hall, Tschl ; in Switzerland, at Rheinfelden, Schweizerhall, Lavey, or 
Bex ; or, they may be prepared at home by adding from, according 
27 



418 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

to the size of the bath, one to three pounds of salt to a warm bath. 
For a large child, sea-baths may be recommended ; for weakly chil- 
dren, warm baths with the addition of malt and aromatic herbs. In 
fat scrofulous children, Niemeyer recommends wrapping the whole 
body in wet sheets ; I have seen good results from this in some cases. 
Some physicians also recommend sulphur-springs, especially the hot 
ones, in scrofulous diseases of the joints ; so far, I have seen more 
harm than good from them. You see there is no lack of remedies ; 
still we rarely succeed in improving the constitution bj' them, and can* 
not prevent relapses in all cases. Sometimes, too, the local process 
attains such a grade as to be of itself dangerous to life, and the local 
remedies must be mostly relied on. As before stated, the tendency 
to these diseases greatly decreases in the course of years ; but many 
children die of the diseases of the bones and joints. 

2. The tuberculous dyscrasia. Tuberculosis. The name of this 
disease comes from tuberculum, the nodule, because chronic inflam- 
mations due to this disease appear as small nodules, or tubercles, at 
first scarcely as large as a millet-seed, often microscopic. If you 
analyze one of these nodules with the microscope, you find it to con- 
sist of a number of medium-sized, round cells, which increase in the 
periphery of the nodule, while in its midst the short-lived cells have 
already broken down to a fine, molecular, dry pulp, which, when the 
nodule is very large, becomes yellow and caseous. 

The recent investigations of Schuppel, Lanyhans, Mindfleisch, 
and others agree that large multinucleated masses of protoplasm, so- 
called giant cells, are often found in the centre of young tubercles ; 
we shall speak of these further when describing the new formation 
of bone. The nuclei in the giant cells of tubercle are often exqui- 
sitely arranged about the periphery. But these giant cells do not 
always occur in tubercles. We often see in the peritoneum an in- 
discriminate grouping of large and small cells as a commencement 
of tubercle ; and near these distinctly round or very irregular but 
sharply-bounded new formations there are more diffuse (tuberculous) 
infiltrations, which can scarcely be distinguished from ordinary in- 
flammatory infiltration, except by the fact that the cells are nearly 
double the size of wandering cells which form the first cellular infil- 
tration in acute inflammation. 

A great peculiarity, especially noticed by Rindfleisch, is that tu- 
bercle often develops on and in the walls of small arteries and lym- 
phatics, but very rarely in veins. 

There are various views about the origin of the cells which form 
tubercles. If they are wandering cells, they must enlarge very rap- 
idly soon after their escape from the capillaries and veins ; on the 



TUBERCULOSIS 



419 



whole, modern observers are little inclined to this view. Rindfleisch, 
Kundrat, and others hold that tubercle-cells develop mostly from 
proliferation of endothelium, especially that of the blood-vessels, 
lymphatics, and serous membranes. Rindfleisch thinks they may 
also develop from the muscle -cells of the arteries ; Ziegler has 
proved that they may result from confluence of wandering cells. 

Fig. 71 a. 




Giant cells from tubercle in various stages of development. After Langhans. Magnified about 400. 



Regarding the subsequent fate of these small neoplasia, the most 
essential and peculiar thing about them is that vessels do not de- 
velop in them any more than in purely epithelial neoplasia, although 
their periphery is very vascular. Very rarely cases occur where the 
tubercles gradually become filament-nodules. While every other 
neoplasm is accompanied by growth of vessels, in tubercles this is 
wanting entirely, as has been lately shown again by Rindfleisch i 
JTeitzmann, and others. The result of this is that the young neo- 
plasia cannot live long ; it dies in the centre, but the periphery sur- 
vives. The dead centre occasionally breaks down into a fine, punc- 
tate, amorphous substance, which to the naked eye appears as a 



420 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

Fig. 71 b. 




a, Minute tubercles in the peritoneum. 6, Minute tubercles on a cerebral artery, a and b slightly mag- 
nified from preparations of Eindfieiseh. c, Development of minute tubercles in the peritoneum. 
After Kundrat. Magnified 500. 

dry, cheesy pulp ; in short, as a result of its lack of blood-vessels, 
the tubercle undergoes cheesy degeneration. Possibly the tubercle 
might enlarge ad infinitum by new cellular infiltration of the tissue 
around the primary focus, but this rarely happens. The large cheesy 
deposits found in the brain, testicle, etc., in most cases result from 
confluence of numerous small nodules, of which we often find num- 
bers in the vicinity of large caseous nodules. 

This brings us to the relation of the tissue to the tubercle scat- 
tered through it. I would here remark that the miliary nodules 
usually appear in large numbers in the organ or part affected. Just 
around the tubercle there is generally a subacute inflammation with 
free cell-infiltration and vascularization ; this may lead to suppura- 
tive softening of the tissues, chronic abscesses, and ulceration ; thus 
a cavity is formed which contains pus, softened shreds of tissue, and 
caseous tubercle. The inflamed parts around the tubercle may be 
drawn into the caseous degeneration, and a large cheesy deposit 



TUBERCULOSIS. 
Fig. 71 c. 



421 




a, Minute tubercle of a cerebral artery. Magnified 100. &, Commencement of the cellular growth in 
one of the small cerebral arteries. Magnified about 1,000. (I do not think it can be proved whether 
the multinucleated cells are wandering connective-tissue, endothelial, or muscle cells, or whether 
they are due to the transformation of the intima to protoplasm.) Both drawings are from 
preparations of Rindfleisch. 

forms, which shall contain the primary tubercle ; this may subse- 
quently soften by peripheral suppuration, or after encapsulation may 
become calcareous. If tubercles form in mucous membranes, as in 
the larynx, intestine, ureters, bladder, or uterus, besides the tuber- 
culous infiltrations and ulcerations there is purulent catarrh, with 
free detachment of epithelium, especially in the pulmonary alveoli 



422 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

(desquamative pneumonia, Buhl). In all of these cases the diseased 
part may be, but unfortunately rarely is, encapsulated by firm con- 
nective tissue, after undergoing metamorphosis ; and after evacuation 
or calcification of the contents, the capsule may shrink to a firm cic- 
atrix. But in serous membranes, and especially in the peritoneum, 
the inflammation caused by presence of tubercles leads at once to 
development of connective tissue, which not only encapsulates the 
nodules, but causes such an intimate adhesion of the intestines to 
each other and to the walls of the abdomen, that they can scarcely 
be separated on autopsy. 

As regards the occurrence of tubercles in different organs, none 
are exempt, though some are more predisposed than others. Tuber- 
cles are most frequently found in the lungs, especially at their apices; 
there are usually many at one time ; they unite, the walls of the 
bronchi are implicated in the process, they are destroyed, and the 
caseous, partially-softened contents of the tubercles are coughed up; 
sometimes blood-vessels are ruptured, giving rise to spitting of 
blood or pulmonary haemorrhage. A space thus left by softened 
tubercle is called a cavity. It is not our object to enter more into 
detail ; you will hereafter learn enough of this unhappy disease in the 
clinic. Next to the lungs, the most frequent location of the disease 
is in the laryngeal mucous membrane, then in the intestinal mucous 
membrane, even in the rectum, where the tuberculous ulcers and ab- 
scesses also acquire a surgical interest. Tubercles also occur in the 
bones, especially in the spongy ones, such as the calcaneus, bodies 
of the vertebrae, and upper epiphyses of the tibia. Although the 
lymphatic glands are often diseased in tuberculosis, miliary tubercle 
proper is hardly ever seen in them; still Schuppel found them 
there also. 

The views as to the etiology of tuberculosis have changed wonder- 
fully of late years. Formerly it was not doubted that it was partly 
an idiopathic disease, partly due to hereditary predisposition. Hence 
we spoke of a tuberculous as we did of a scrofulous diathesis, and the 
two were considered as related, although not identical. JLaennec 
started the view that the small nodular neoplasias (gray miliary tuber- 
cles) were the primary development, and by confluence and growth led 
to the destruction of the affected tissues. The division of tubercles 
into miliary gray points and into cheesy nodules, the very peculiar 
acute miliary tuberculosis, the connection of tuberculosis with other 
and especially with chronic suppurative inflammations and those 
tending to caseous degeneration, were gradually developed and in 
many places remain obscure, although the idea of tubercle has been 
rendered more limited and precise by Vtrchotv, so that at present 



TUBERCULOSIS. 423 

every new formation that has undergone caseous degeneration is not 
considered as tubercle. It was reserved for Buhl, by careful experi- 
ments, to arrive at the idea that acute miliary tuberculosis was the pro- 
per type of tuberculous disease ; he found it mostly combined with old 
caseous or purulent inflammatory foci ; he made the bold assertion 
that it always resulted from absorption of substances from these foci. 
According to this, tuberculosis was an infectious disease, a sort of 
nodular exanthema on and in internal organs, caused by the absorp- 
tion of an injurious substance, particularly from old caseous points of 
inflammation in the lymphatic glands, lungs, bone, etc., and some of 
these particles may have a specific infectious action, as emboli in the 
lymph- and blood-vessels. Investigations of late years have shown 
that many destructions — in the lungs, for instance — which previ- 
ously had been considered due to miliary tuberculosis as a matter of 
course, are inspissated, caseous, and partly-softened spots, that must 
be regarded as the result of a simple chronic, ulcerative inflammation, 
as no miliary tubercles are found in them, but only large-celled infil- 
tration. It seems, indeed, that even in pulmonary tuberculosis the 
formation of true tubercle is to be regarded as secondary and fre- 
quent, but by no means necessary. Niemeyer deserves great credit 
for his practical application of this view, according to which a diathe- 
esis to chronic purulent inflammations of certain organs, but not the 
tuberculous infection, would be congenital. This view is of late 
greatly supported by the fact that attempts to render animals, espe- 
cially Guinea-pigs and rabbits, tuberculous, have succeeded. In these 
little animals irritation of very short duration excites inflammation with 
caseous purulent products, and from this focus results a tuberculous 
dyscrasia, which evinces itself in the production partly of miliary tuber- 
cles, especially on the serous membranes, partly of yellow nodules in the 
lung, liver, spleen, etc., and causes death. These very interesting ex- 
periments, which were begun by Villemin, and repeated by Lebert and 
Wyss, Fox, Klebs, Cohnheim, Waldenburg, Menzel, and others, with 
the same result, but with different interpretations, seem to me to prove, 
what I have always maintained, that tubercle is merely a peculiar 
form of inflammatory new formation ; that is, that BuhVs view is 
correct. But it is important to remember that these inoculations 
only succeeded in animals having a tendency to cheesy degeneration, 
as rabbits, etc. Hindfleisch says these animals become tuberculous 
whenever they have a chronic inflammation. In dogs the inoculation 
does not succeed. 

If from what has just been said we recognize to the full extent 
the immense progress recently made in the knowledge of tuberculosis, 
still we must not fail to see that it does not fully explain the interest- 



424 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

ing connection between some chronic surgical diseases and tubercu- 
losis of internal organs, especially of the lungs. Although there are 
a good many cases where pulmonary tubercles follow chronic sup- 
puration of bones or joints, and caseous degeneration of swollen 
lymphatic glands, just as often death of the patient results, after 
years of illness, from exhaustion, and on section we do not find a 
trace of tubercle. Under some circumstances, too, there is no ab- 
sorption of the caseous masses, or else, if absorbed, they do not in- 
duce tubercle. This would go to prove that there must not only be 
a disposition of inflammatory foci to become caseous, but also a dis- 
position to the dissemination of tubercles, and that these two dispo- 
sitions are not necessarily combined as in the rabbit and Guinea-pig. 
The fact that around a small inoculation a cheesy focus forms, and 
from this disease is disseminated to the internal organs, is a peculiar- 
ity of these animals, as it is of some human beings. This peculiarity 
is called the tuberculous diathesis. Nor must I hide from you that 
some pathologists only acknowledge a frequent coincidence between 
chronic suppurating or caseous foci and tubercle, and refer both to a 
common, unknown cause. But all this cannot prevent me from rec- 
ognizing the exceeding value of the above-described recent observa- 
tions, and regarding them as one of the greatest advances of modern 
pathology. 

The new etiology of tuberculosis has given treatment a peculiar, 
and, at a casual glance, a changed position. We now have to ask 
ourselves the following question : Is there any remedy or mode of 
treatment by which we can prevent a person, who has on or in him 
any caseous pus, from being infected with tuberculosis ? To this we 
must at once say no. The mode of infection is so little known, that 
on this account alone we could not speak of its prevention. The in- 
terval between the development of the primary point of inflammation 
and the succeeding tuberculous infection is entirely incomputable. 
In some cases the formation of tubercles in the lungs appears to fol- 
low almost on the heels of chronic bronchial catarrh, while in other 
cases the two forms of disease are separated by years. Typical tuber- 
cles may also dry up and become indurated in various ways, or they 
may rapidly increase, unite, and soften. In short, the variety of the 
process is very great. But all this gives no starting-point for the 
treatment. As regards hereditary influence, to which so much im- 
portance is properly attached in tuberculosis, some enigmas have been 
solved by, and some former experiences readily adapt themselves to, 
the new views. If true tubercle could only develop from infection 
through the patient himself, of course there could be no talk of direct 
inheritance of tuberculosis in the strict meaning of the term. Only 



GOUT. 425 

the tendency to chronic inflammations, ending in suppuration and 
caseous degeneration, is hereditary ; in other words, the scrofulous 
diathesis, not the tuberculous, is hereditary. We must bear this in 
mind ; the experience of family physicians agrees with it entirely ; 
but we must understand that such general rules are only true in 
theory. The hereditary tendency to diseases of certain organs, and 
to certain forms of disease, is such a complicated question that we 
should be very reserved in stating general laws about it. Apart 
from the occasional accidental complications, such as meningitis, 
haemorrhages, pneumothorax, empyema, peritonitis from perforation 
of intestines, pyaemia, etc., tuberculosis may prove fatal by extensive 
suppuration and the rapid febrile marasmus, or by amyloid degener- 
ation of internal organs due to the suppuration, or, lastly, by acute 
miliary tuberculosis, i. e., by an extensive eruption of tubercles in 
internal organs, accompanied by general poisoning, where the pa- 
tient is in a typhoid state. In the earlier stages recovery may take 
place, but leaving a tendency to relapse. 

If we put together what may be said about the indications for 
treatment of tuberculosis, it would be about as follows : We cannot 
prevent either the development or progress of tubercles. Hopeless 
as this sounds, it remains to be added that medical care may accom- 
plish something in hindering the development of those processes 
which are so often followed by tuberculosis. The early, careful, 
general dietetic and local treatment of chronic diseases of the bones 
and joints, and even the amputation of limbs, or the resection of 
bones at the proper time, may prevent the development of tubercle. 
In the same way, great care of catarrhs of all sorts, and their most 
perfect removal, is undoubtedly the most effectual thing we can do 
to remove the tuberculous infection. In tuberculosis the treatment 
is the same. All the remedies, baths, and places for treatment, that 
are prescribed, have for their object — 1, to remove or diminish the 
existing catarrh or other primary disease ; 2, to improve the nutri- 
tion of the patients, who are generally emaciated ; 3, to avoid every 
thing that can render the patients feverish. T must leave it for the 
lecturer on clinical medicine to make you better acquainted with 
the important principles of treatment in this frequent and fearful 
disease. 

3. Arthritis, or gout, is a tendency to disease which usually ap- 
pears first about the thirtieth to the forty-fifth year of life and later ; 
it is often confounded with chronic rheumatism, but really differs 
from it considerably. True gout is a rare disease with us, and is dis- 
tinguished from rheumatism by the fact that it occurs in attacks, 
often recurs only once a year, or at stated intervals, while meantime 



426 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

the individual remains perfectly well. Gout is a disease of the rich, 
and, as old physicians who had it themselves used to say, of wise men. 
It occurs chiefly in men who lead a comfortable, inactive life ; it not 
unfrequently descends to the next generation, but always appears 
first after middle age. Harvey, Sydenham, and many other cele- 
brated physicians, suffered from gout. The inflammations occurring 
in gout are chiefly limited to certain joints, and the parts around 
them. The joint between the metatarsus and the first phalanx of the 
big toe is affected particularly often ; this is the seat of true podagra. 
The wrist and the joints of the phalanges may also be attacked by 
gout ; here it is called chiragra. The skin over the joint is impli- 
cated in these inflammations. During the attack it becomes bright 
red and very sensitive, as in erysipelas ; and, in rare cases, ulcers 
may form during this process. Arterial thickenings (atheroma of the 
artery), with their occasional results, cerebral apoplexy and senile 
gangrene, are not unfrequent in arthritic patients. Corpulence, dis- 
eases of the liver and kidneys, may also accompany gout ; gravel, 
especially a fine granular excretion of uric or oxalic acid from the 
kidneys into the bladder, is not unfrequent, but, just as frequently, 
large renal and vesical calculi develop. In the diseased joints and 
sheaths of the tendons considerable quantities of urates have been 
seen, occasionally in such quantities that they covered the articular 
surfaces and capsule like a white granular coating. An attack of 
gout is usually preceded for some time by a general feeling of being 
out of sorts, which disappears as soon as the inflammation attacks 
some external point, usually a joint. These inflammations last two 
or three weeks, and then subside, often leaving permanent thickening 
of the joint ; but in other cases the diseased limbs often remain un- 
changed for years. In some old arthritic patients these stone-like 
gout-nodules are also found in the skin, as in that of the ear, as well 
as in the joints and sheaths of the tendons. If these nodules break 
off, the masses of lime and urates may be scooped out with an ear- 
spoon ; the complete suppuration and closure of these open and 
very painful gouty nodules then last for months. Operations with 
the knife in such cases should be carefully avoided. The ordinary 
attack of podagra never ends in suppuration, always in resolution. 
From this etiological relation of the abnormal deposits of uric acid 
to the joint affection, gout has also been called arthritis urica. 

The treatment of the attack of gout, of the gouty articular in- 
flammation, is to be distinguished from the general treatment. The 
former almost always runs a typical course, which is not materially 
changed by treatment. The first indication for medical aid is to al- 
leviate the pain by moderating the inflammation ; for this purpose 



SYPHILIS. 427 

ice might answer very well, if there were not certain reasons for 
fearing its effects, for, from the frequent presence of atheroma of the 
smaller arteries, great cold might induce gangrene. There is not 
much to be said against the application of cold compresses, cold fo- 
mentations with lead-water, weak solutions of nitrate of silver, or 
local applications of leeches ; but many gouty patients prefer greas- 
ing the joint and wrapping it in wadding. Profuse diaphoresis, in- 
duced by hot tea and hydropathic packing, is said to shorten the 
attacks. In the constitutional treatment of the arthritic diathesis, 
mineral waters take the first rank. Gouty patients should be ad- 
vised to use the waters of Karlsbad, Kissingen, Homburg, Vichy, 
and other saline springs, also the thermal waters of Teplitz, Gastein, 
Wiesbaden, and Aix-la-Chapelle. But we may expect an acute 
attack of gout to follow the use of warm baths. 

4. The scorbutic dyscrasia manifests itself in great fragility of 
the capillary vessels, and consequent subcutaneous haemorrhages, 
which result from ruptures of the vessels or from diapedesis, and 
may be induced in frogs by poisoning them with ordinary salt. This 
disease is supposed to be due to dissolution of the blood, without 
any accurate description being given of the blood-change causing 
the change in the vessels. The disease is almost entirely endemic, 
for instance, on the shores of the Baltic, and, in a surgical point of 
view, is not very interesting. When treating of ulcers in the next 
chapter, we shall refer to it again. 

5. The syphilitic dyscrasia. Although I do not propose to in- 
clude syphilis in the subjects of these lectures, still, for the sake of 
completeness, I must make some remarks on it. This, like the above 
diathesis, developed in man at some time, but now it is spread entire- 
ly by inoculation. The person inoculated is syphilitic from the mo- 
ment the virus takes effect. In speaking of syphilitic diseases in 
general terms, three different diseases are included : (1) gonorrhoea, 
a blennorrhoea of the vagina, then of the urethra, which thence oc- 
casionally extends to the excretory ducts of the testicles and pros- 
tate, and may induce gonorrhceal prostatitis or orchitis ; prolifera- 
tions of the papillary bodies, in form of the so-called condylomata 
(from fcovdvXog, a button-like prominence on bone), often occur where 
gonorrhceal pus stagnates ; (2) the soft chancre, an ulcer, usually on 
the glans and prepuce, which frequentl} r , through the lymphatic ves- 
sels, excites an inflammation of the inguinal glands, which has a great 
tendency to go on to suppuration ; (3) the proper syphilitic ulcer, 
the indurated chancre. In this the general disease occurs at the 
time of inoculation, while the first and second form remain relatively 
local. In inoculation with the secretion of a true syphilitic ulcer, 



428 CHRONIC INFLAMMATION OF THE SOFT PARTS. 

the entire organism is infected at once ; a series of chronic inflamma- 
tions occur in the most varied organs, which have at first a more pro- 
ductive character, but soon lead to disintegration of the infiltrated 
tissue and assume an ulcerative destructive character. The following 
symptoms may appear in syphilis : eruptions on the skin of blotches, 
papules, desquamations, and nodules ; ulcers in the fauces, on the lips 
and tongue, and about the anus ; osteoplastic and ulcerative periosti- 
tis and ostitis, especially on the tibia, cranial bones, sternum, etc. ; 
chronic inflammations of the greatest variety, usually with caseous 
degeneration in the testicles, liver, brain, and possibly in the lungs. 
The nodular circumscribed product of syphilis is called by Virchow 
"gummy tumor," by E. Wagner "syphiloma." Syphilis may also 
be inherited ; children are born with it ; the dyscrasia may be car- 
ried by the sperm to the ovum, or be in the ovum. It is still dis- 
puted whether a healthy woman who has been impregnated by a 
healthy man, and has become syphilitic during pregnancy, can con- 
vey the disease to the foetus, and whether a foetus begotten by a 
syphilitic man who has no ulcer on the penis can infect the healthy 
mother. It is also disputed by some that the venereal poison can 
pass through the placenta. 

Gonorrhoea and the soft chancre are local diseases, and are to be 
treated as such. Formerly soft and indurated chancres were regarded 
as two forms of syphilis, with many connecting links ; of late the 
dualistic theory seems to gain more and more supporters, although 
there is still much discussion on the subject. Many surgeons con- 
sider mercury as a specific, or as a sort of antidote, in syphilitic dys- 
crasia. It seems to me proved by recent observations that this is not 
exactly true. Constitutional syphilis, which only attacks a person 
once, may in the course of time be to some extent gotten rid of by 
the change of tissue ; hence all remedies that greatly promote the 
change of tissue are in a certain sense antisyphilitic. Most frequent- 
ly treatment by sweating or purging is resorted to ; occasionally 
syphilis is cured by a treatment of six weeks ; in some cases these 
modes of treatment must be continued with interruptions till they 
prove successful, and, finally, some cases are entirely incurable. Oc- 
casionally mercury, by inunction or internally, in various preparations, 
continued a long time, removes the symptoms of syphilis with sur- 
prising rapidity ; and hence, in cases where we desire to arrest as 
quickly as possible certain ulcerative forms, especially in the bones, 
it will maintain its value. Of late it has been much doubted if mer- 
cury alone can cure syphilis, and at the same time it has been shown 
what injury may be induced by continued use of mercurials, by a sort 
of chronic mercurial poisoning (hydrargyrosis). The mercurialists 



LOCAL TREATMENT OF CHRONIC INFLAMMATION. 429 

and anti-mercurialists have disputed for a long time ; and in the last 
decennium it has entered new stages, without, however, having 
brought all physicians to a conclusion on this question. I incline to 
the views of the anti-mercurialists. In the course of your studies 
you will hear still more about this important and interesting point. 
Iodide of potash is generally recognized as one of the most important 
and efficacious remedies for syphilitic diseases of the bones and glands, 
while it does little good in other syphilitic diseases. 



LECTURE XXX. 

Local Treatment of Chronic Inflammation: Rest, Compression, Resorbents, Antiphlo- 
gistics, Derivatives, Fontanels, Setons, Moxee, the Hot Iron. 

It still remains, at the close of the chapter on chronic inflamma- 
tion, to run through the remedies that we may employ locally, and 
which are more or less prominent according to the case. Where we 
do not succeed in finding a constitutional cause for a chronic inflam- 
mation, we are limited to local remedies. 

Absolute rest of the inflamed part is necessary in all cases where 
there are pain and congestion. When possible, these are combined 
with elevation of the diseased part, by means of suspensories or pads 
placed beneath. This, by facilitating the return of the blood, has 
the effect of relieving and finally removing the venous tension, which 
is favored by the absolute rest, and hence is especially important in 
cases where venous congestion has induced or increased chronic 
inflammation. 

Compression. This is applied by wrapping the diseased part 
with moist or elastic bandages, plaster-dressing, strips of adhesive 
plaster, or even by covering with moderate weights (as in compressing 
swollen inguinal glands). Compression is one of the most important, 
and, when made to act regularly, is the most certain means of re- 
moving chronic inflammatory infiltrations. 

Massage, of which we spoke when treating of distortions, is par- 
ticularly serviceable for getting rid of old infiltrations; it sometimes 
accomplishes wonders ; but this method of treatment must be fol- 
lowed with great energy and perseverance. 

Moist warmth in the form of cataplasms, continually applied, is 
also very efficacious, as are also the hydropathic wraps. These are 
applied by dipping a cloth, folded several times, in cold water, wring- 
ing it out, enveloping the affected part with it, and covering with 
some air-tight substance, such as oil-silk, gutta-percha cloth, etc., and 



430 



CHRONIC INFLAMMATION OF THE SOFT PARTS. 



renewing this dressing every two or three hours. The skin, at first 
much cooled, soon becomes very warm ; then the dressing should be 
renewed, so that the cutaneous vessels are kept active by the change 
from cold to warm, and are thus placed in the best state for absorb- 
ing. In some cases these wraps are very useful. 23 

Resolvent remedies. Fomentations with lead-water, infusion of 
arnica, camomile-tea, etc., have some reputation as resolvent appli- 
cations, which they do not, however, deserve ; they rather belong to 
the category of inactive domestic remedies. Mercurial salve, mercu- 
rial plaster, ointment of iodide of potassium, and tincture of iodine, 
are also absorbents which may be employed alternately in chronic 
inflammations. I am far from denying them any efficacy in such 
cases; but you must not expect too much from them. Of late, 
tincture of iodine, in doses of 5-10 drops, has been injected into 
lymphatic glands, but with very uneven effect. I pass over a series 
of resolvent plasters ; they do little good in this way ; their effect is 
partly as slight irritants to the skin, partly as protective coverings ; 
in some cases I order such plasters to prevent the patient from ap- 
plying something injurious ; mercurial plaster only has a medicinal 
effect when used for a long time. I may mention electricity as a 
discutient remedy ; its effect does not seem to be very great, but 
cases are reported where it has been used with advantage ; further 
investigations should be made on this point. 

Antiphlogistic remedies proper, such as ice, leeches, cups, etc., 
about which you will learn in the clinic, are rarely used, and are only 
of slight temporary benefit in chronic insidious inflammations ; but, 
in intercurrent acute attacks, they are just as useful as in primarily- 
acute inflammations. Some surgeons of the present time, especially 
Von Esmarch, use ice continuously in chronic torpid inflammations, 
and praise the result of this treatment. 

Derivatives. These play an extensive role in the treatment of 
chronic inflammations. They are so named because they are said to 
remove the inflammation from its location to other points where it will 
be less dangerous ; there are remedies by which we may induce cutane- 
ous inflammations of varied grades, and which have been proved by 
careful observers to have an excellent curative effect. The physio- 
logical explanation of the mode of action of these derivatives is as 
yet an unsolved problem. It is supposed that, from the application 
of these remedies near a point of chronic inflammation in a bone or 
joint, the blood and fluids are drawn outward to the skin. In some 
cases of inflammation accompanied by little energy or vascularization, 
the derivatives certainly have rather an opposite effect ; i. e., the new 
acute inflammation induced in the immediate vicinity of the chronic one 



LOCAL TREATMENT OF CHRONIC INFLAMMATION. 431 

causes stronger fluxion to these parts, and arouses the chronic, torpid 
inflammation into an energetic, active state. But we shall not worry 
ourselves trying to discover the physiological way in which these 
remedies act ; this has always been a very thankless task. The fol- 
lowing remedies of this class are practically useful : Nitrate of silver 
in concentrated solutions mixed with fat, and rubbed on the skin a 
couple of times daily, induces a dark-brown hue, with silvery lustre 
in the skin, and a slow detachment of epidermis. It is one of the 
mildest derivatives, and is particularly suited to the joint diseases of 
sensitive children. Tincture of iodine, especially the strong tincture 
(iodine 3 jto absolute alcohol |j dissolved with ether), if applied to 
the skin morning and evening, induces a tolerably sharp burning 
pain ; if this painting be continued two or three days, the epidermis 
is elevated into a vesicle, occasionally all over the space where the 
remedy has been applied. Blistering plasters act more rapidly ; they 
consist of powdered cantharides (lytta vesicatoria, meloe vesicatorius) 
rubbed up with wax or fat, and spread on linen, leather, or oiled mus- 
lin. Well-made ordinary emplastrum cantharidum, in pieces as large 
as a franc or a dollar, is fastened on the skin, and in twenty-four hours 
a vesicle forms under it ; this is to be punctured, and a piece of wad- 
ding applied over it ; this dries on and becomes detached in three or 
four days, at which time the detached hard layer of the epidermis has 
been regenerated from the rete Malpighii. A large spanish-fly blister 
may be applied once, or a small one may be applied new every day ; the 
latter method is called vesicatoires volantes. Lastly, we may apply 
plasters containing only a small amount of cantharides, and only in- 
ducing continued redness. This is the emplastrum cantharidum per- 
petuum, or emplastrum euphorbii ; it is worn several days or weeks in 
succession. Although the favorable action of the above derivative 
remedies in chronic inflammation cannot be denied, I may say that 
particularly tincture of iodine and blisters do much more good in sub- 
acute inflammations, or the slight intercurrent acute attacks in chronic 
inflammation, than in the painless torpid forms. 

The remedies still left to mention are those followed by long-con- 
tinued suppuration, a suppuration which is kept up by artificial ex- 
ternal irritation, according to the will of the physician. Their use is 
so diminished during the last ten years that at present very few sur- 
geons resort to them. 

Tartar-emetic ointment and croton-oil. When repeatedly applied 
to the skin for a length of time, in about six or eight days, or in irrit- 
able skins earlier, both of these induce a pustular eruption, which is 
not unfrequently painful. When these pustules begin to show them- 
selves, we stop the applications and allow the pustules to heal. Con- 



432 



CHRONIC INFLAMMATION OF THE SOFT PARTS. 



siderable cicatrices not unfrequently remain ; the effect of these rem- 
edies is rather uncertain, so that they are not often used. 

By fonticulus or a fontanel (from fons, well), we mean an inten- 
tionally-induced wound of the skin that is kept suppurating; it 
may be induced in various ways. You may apply an ordinary blister- 
plaster, then cut the blister and daily dress the part denuded of epi- 
dermis with ointment of cantharides or other irritating salve. You 
will thus induce a suppuration that you may keep up as long as you 
continue this mode of dressing. Another way of making a fontanel 
is to incise the skin and place a number of peas in this incision, re- 
taining them in position by adhesive plaster. The peas swell up, and 
are to be daily renewed ; they irritate the wound as foreign bodies ; a 
simple ulcer is thus artificially induced. It is always simplest to 
make the fontanel with an incision, but we may burn the skin thor- 
oughly with any caustic, and keep the resulting wound suppurating 
by the introduction of peas. 

The seton is a small strip of linen, or an ordinary lamp- wick, which 
is drawn under the skin by means of a peculiar needle. The seton- 
needle is a moderately-broad, rather long lancet with a large eye at 
its lower end, to carry the seton. Setons are generally applied to the 
back of the neck in the following manner : with the thumb and fore- 
finger of the left hand you lift as large a fold of skin as possible, trans- 
fix it at its base with the threaded seton-needle and draw the latter 
through. After the seton has lain quiet a few days, and suppuration 
begins, pull it forward and cut off the part impregnated with pus ; re- 
peat this daily. Granulations form in the whole canal occupied by 
the seton ; these secrete quantities of pus. The seton is worn for 
weeks or months, and removed when we wish the suppuration to 
cease. 

Another mode of inducing continued suppuration is by making a 
slough in the skin by means of heat and preventing the resulting granu- 
lating wound from healing by irritating dressings or by introducing 
peas ; this may be kept up a longer or shorter time, according to the 
effect desired. For this purpose there are two modes of operation, by 
the so-called moxa and by the hot iron. Moxag are thus prepared : a 
wad of cotton is tied together with silk thread, then soaked in spirits, 
held on the skin with forceps and there burned. Various grades of 
burn may be induced by the longer or shorter action. There are other 
modes of preparing moxae, which, however, I shall not here describe, 
as moxae are now little used. If you wish to induce a slough in the 
skin, it may be most simply done by strong caustics and caustic 
pastes, or by the hot iron. The cautery-irons used in surgery, already 
mentioned among the hemostatic remedies, are thin iron rods a foot 



LOCAL TREATMENT OF CHRONIC INFLAMMATION. 433 

long, with wooden handles, and with a button-shaped, cylindrical, or 
prismatic end, which is placed in a basin of hot coals till it reaches 
a red or white heat. With this, various grades of burns, even to 
charring the skin, and burns of variable size, form, and depth, may be 
induced, according as we desire extensive suppuration, or several dis- 
tinct small ulcers. 

It would lead me too far, and not be very comprehensible for you 
at present, were I here to enter into an exhaustive criticism about the 
choice and various gradations of the above remedies. These are 
things that you learn more quickly and certainly in the clinic, from the 
remarks on an individual case. I will only observe that the applica- 
tion of the more intense derivatives, such as fontanels, moxse, setons, 
and the hot iron, to children and susceptible, delicate persons, should 
be made very carefully, and had better be avoided. I scarcely ever 
use the hot iron as a derivative, though I sometimes employ it to 
destroy spongy granulations in caries, occasionally with very good 
effect. 

Almost all classes of remedies have for a time been somewhat the 
fashion, according to the prevailing theories, and so there was a time 
when moxae, the hot iron, or fontanels, were praised as universal rem- 
edies in every chronic inflammation. A fontanel was applied on the 
arm to protect the person against rheumatism, haemorrhoids, tubercu- 
losis, or cancer, with the idea that with the pus from the fontanel all 
morbid juices, the materia peccans, were thrown off from the body. 
In the same way, formerly, at certain seasons, purgatives, emetics, 
venesections, etc., were resorted to yearly. Even at present you will 
hear old practitioners tell gleefully how this or that patient was pre- 
served from a multitude of ills by the application of a fontanel. I 
shall not presume to criticise what may be accomplished by this treat- 
ment, for, as was mentioned, we are far from knowing how to meas- 
use its physiological effect ; but we should mistrust the action of reme- 
dies that are recommended against all possible diseases. 



28 



CHAPTER XV. 
ULCEUS. 

LECTURE XXXI. 

inatomy. — External Peculiarities of Ulcers ; Form and Extent, Base and Secretion, 
Edges, Parts around. — Local Treatment according to the Local Condition of the 
Ulcer ; Fungous, Callous, Putrid, Phagedenic, Sinuous Ulcers, Etiology, Contin- 
ued Irritation, Venous Congestion, Dyscrasial Causes. 

The study of ulcers naturally follows that of the chronic inflam- 
mations. Physicians practically agree as to what an ulcer is, and 
whether any given wounded surface is to be so regarded ; but, to give 
a short definition of it is about as difficult as it is to define any other 
object in medicine or natural history. To give you a proximate de- 
scription of it, we may say, an ulcer is a wounded surface which 
shows no tendency to heal. Here you see at once, that every large 
granulating wound with free proliferations, which halts in its progress 
toward cure, may also be regarded as an ulcer, and, in fact, Mush, to 
whom we owe our most comprehensive nomenclature of ulcers, desig- 
nates granulating wounds as ulcus simplex. 

From personal observations and examinations we conclude that 
ulceration mostly starts from chronic inflammation, and is always pre- 
ceded by cellular infiltration of the tissue. 

This inflammation may be located in the depth of the cutis, in 
the cellular tissue, muscles, glands, periosteum, or bones; in the 
centre of the inflamed spot there is suppuration, caseous degenera- 
tion, or some other form of softening and breaking down, with grad- 
ual peripheral progression and perforation of the skin from within 
outwardly. The excavated ulcer is thus formed ; as before stated, this 
is a diminutive cold abscess. 

Just as often the process is in the superficial layers of a membrane, 
and we have the open cutaneous ulcer. We will illustrate this by an 



ANATOMY OF ULCERS. 



435 



example. Let us suppose that from any of the above-mentioned 
causes we have a chronic inflammation in the skin of the leg, say on 
the anterior surface of its lower third. The skin is traversed by di- 
lated vessels, hence it is redder than normal, it is swollen, partly 
from serous, partly from plastic infiltration, and it is sensitive to 
pressure. Wandering cells are infiltrated, especially in the superficial 
parts of the cutis ; this renders the papillae longer and more succulent ; 
the development of the cells of the rete Malpighii also becomes more 
plentiful, its superficial layers do not pass into the normal, horny 
state ; the connective tissue of the papillary layer is softer and be- 
comes partly gelatinous. Now, slight friction at any point suffices 
to remove the soft, thin, horny layer of the epidermis. This exposes 
the cell layer of the rete Malpighii ; new irritation is set up, and the 
result is a suppurating surface, whose upper layer consists of wan- 
dering cells, the lower of greatly degenerated and enlarged cutane- 
ous papillae. If at this stage the part be kept at perfect rest, and 
protected from further irritation, the epidermis would be gradually 
regenerated, and the still superficial ulcer would cicatrize. But 
usually the slight superficial wound is too little noticed, it is exposed 
to new irritations of various kinds ; there are suppuration and molecu- 
lar destruction of the exposed inflamed tissue, then of the papillae 
and the result is a loss of substance which gradually grows deeper 
and wider ; the ulcer is fully formed. The accompanying figure is 
the section of a spreading ulcer of the skin ; it formed the basis of 
this description (Fig. 72). 

Fig. 72. 




Cutaneous ulcer of the leg. Magnified 100 diameters ; after Fdrster. Atlas, Taf. XI. 



At a you see the cutis already somewhat thickened, toward b 
its papillae are enlarged, while the vascular loops increase, and the 
connective tissue is more richly strewn with cells ; at b is the fully- 
formed ulcerated surface ; at c the epidermis is much thickened and 
forms the indurated border of the ulcer. 



436 ULCERS. 

On the mucous membrane the process is the same : at first there 
is a lively emigration of young cells on the surface ; this is soon ac- 
companied by a moderate degree of serous and plastic infiltration in 
the connective tissue of the mucous membrane ; the mucous glands 
secrete plentifully. As already stated, it was believed, until within a 
short time, that catarrhal pus was of a purely epithelial character; 
now there is rather an inclination to the view that the elements of 
catarrhal secretion also are wandering white blood-corpuscles. Con- 
tinued irritation of a mucous membrane affected with catarrh is 
followed by softening and breaking down of the tissue, as we de- 
scribed to be the case in the cutis ; then we have a catarrhal ulcer. 

There is another and more acute mode of formation of ulcers, viz. : 
from pustules that do not heal, but which enlarge after evacuation of 
the pus, and keep up an acute inflammatory character, as the soft 
chancrous ulcer. And such ulcers resulting from ecthyma pustules, 
without any preceptible specific dyscrasia, are particularly frequent 
on the legs of young, full-blooded, and otherwise healthy persons ; we 
know nothing definite about their causes ; they often have a prolifera- 
ting fungous form, but at other times induce rapid destruction of tis- 
sue. But this acute commencement of ulcers is much rarer than the 
chronic. Some diseases are only half-correctly called ulcers, as the 
" typhous ulcer ; " in typhoid fever there is an acute progressive in- 
flammation of Peyer's plaques, which in many cases ends in gangrene, 
with necrosis of the inflamed portion of mucous membrane ; what re- 
mains after throwing off of the slough is a granulating surface, which 
usually cicatrizes rapidly ; strictly speaking, this granulating surface 
is not an ulcer, it only becomes so when it does not heal normally. 
Of this, more hereafter ; we may use these expressions more freely, 
when we understand the process perfectly. 

From this description you see that, in ulceration as in inflamma- 
tion^ two opposite processes are combined — new-formation and de- 
struction; the latter results from liquefaction of the tissues, i. e., 
through suppuration, or molecular disintegration, or both together. 
There can be no doubt of the antagonistic relations of new formation 
and destruction to each other in the examples adduced, for it is evi- 
dent that there the former preceded the latter. But you may also 
imagine that in a previously healthy portion of skin there might be 
a disturbance of nutrition of such a nature that disintegration of tis- 
sue is the first step, as you have already learned from the section on 
gangrene. Then on the border of the healthy portion of skin, which 
retains its vitality, there is a new formation of young cells, and, if the 
parts adjacent to the primarily necrosed spot be healthy, there must 
result a granulation surface ; but, if the parts be not healthy, and have 



NOMENCLATURE OF ULCERS. 437 

only a slight amount of vitality, there also we shall have disintegra- 
tion instead of active inflammatory new formation ; an ulcer will thus 
be formed which will spread gradually. This course, of an ulcer 
occurring primarily with molecular disintegration without precedent 
cellular infiltration, rarely presents itself in practice. Strictly speak- 
ing, molecular disintegration and gangrene are but quantitative varie- 
ties of the same process, viz., the death of certain portions of tissue ; 
cases occur where ulceration and gangrene are very closely associated, 
as in hospital gangrene, of which we have already spoken ; but, as 
before said, an inflammatory infiltration usually precedes the disin- 
tegration. 

The above observations, which show the relation of ulceration on 
the one hand to the new formation, on the other to the gangrene, will 
have rendered evident the difficulty of preserving systematic divisions 
of the course of this disease. But do not be afraid that I am going 
to confuse you : we will enter at once on the special peculiarities of 
ulcers, you will understand then more readily ; here we shall only add 
that, according to the vital process, all ulcers may be divided into two 
chief varieties, viz., those where the new formation predominates, 
which we shall designate briefly as proliferating ulcers, and those 
where suppuration and disintegration are more prominent, which we 
shall call atonic or torpid ulcers. Between these two extreme boun- 
dary-points of the anatomical and vital peculiarities of ulcers, there 
are numerous intermediate forms. 

To induce healing of an ulcer, the first requirement is arrest of 
the disintegration on the surface, next that the floor of the ulcer as- 
sume, at least approximately, the character of a healthy granulating 
surface, which goes on to cicatrize in the usual way. In torpid, atonic 
ulcers it is also absolutely necessary that there should be a free de- 
velopment of vessels and stronger cells, which do not lead to sup- 
puration, but to connective-tissue new formation; in proliferating 
ulcers, on the other hand, the new formation must be brought back to 
the normal size. As you will readily perceive, on reflection, this gives 
the indication for the local treatment to be followed in either case, to 
which we shall soon refer. 

The nomenclature of ulcers varies greatly, according to the pecu- 
liarities that are made especially prominent. From the mode of ori- 
gin, just as in other chronic inflammations, we may distinguish two 
classes, or chief varieties, viz., idiopathic and symptomatic ulcers. 
Idiopathic ulcers are such as result from purely local irritation ; they 
may also be termed irritative ulcers. Symptomatic ulcers are such as 
from some dyscrasia appear as a symptom of constitutional disease, 
without the action of a local irritation on the affected part. This di- 



438 ULCERS. 

vision of the causes of ulcers is, as already stated, the same that we 
have previously studied in chronic inflammation. 

Let us at present leave out of consideration these etiological con- 
ditions, and seek first of all, by attending to the external appearances 
that an ulcer may offer, to give a more perfect representation. 

I will only add here that ulceration may not only occur in normal 
tissue but also in new growths in tumors proper ; both excavated and 
superficial ulcers may form in and on them. In describing an ulcer, 
the following parts are distinguished : 

1. Form and extent of the ulcer. It may be circular, crescentic, 
quite irregular, ring-shaped, superficial, deep ; it may be a canal, lead- 
ing into the deeper parts, a tubular ulcer, a fistula ; as I have already 
told you, these fistulae result from the formation of a point of inflam- 
mation in some deep parts, in a deep layer of the cutis, in the 
subcutaneous tissue, muscles, periosteum, or bones, or even in the 
glands, and gradually ulcerating through till it reaches the surface. 
Hence fistula is always preceded by the formation of an excavated ul- 
$er, of a more or less deeply-seated point of ulceration. 

2. The base and secretion of the ulcer. The base may be shallow, 
deep, or projecting; it may be covered with dirty, badly-smelling 
serous, sanious fluid, or even with gangrenous tags of tissue (sanious 
ulcers) ; an amorphous, fatty, creamy, or smeary substance may cover 
it ; it may also have luxuriant granulations with a muco-purulent 
secretion (fungous ulcers); 

3. The edges of the ulcer are flat or elevated, wall-like, hard 
[callous ulcers), soft, tortuous {sinuous ulcers), zigzag, everted, under- 
mined, etc. 

4. The vicinity of the ulcer may be normal or inflamed, oedema- 
tous, indurated, pigmented, etc. 

These universally employed technical terms suffice for the de- 
scription of any ulcer to a scientific 'person. But, as the terms ex- 
pressing the vitality of the process, as torpid, atonic, proliferating, 
fungous, etc., are briefer, they are more frequently employed ; desig- 
nations referring to the ultimate causes, especially of symptomatic 
ulcers, are also often used. Thus we speak of scrofulous, tuberculous, 
syphilitic, etc., ulcers. 

While we have the local conditions of ulcers fresh in our memory, 
we shall speak of local remedies, as far as their employment depends 
on the condition of the ulcer. A large number of ulcers, especially 
of those that have resulted from repeated local irritations, heal very 
readily. As soon as the diseased parts are under favorable external 
circumstances, and not subject to new irritation, cicatrization often 
begins sDontaneously. It is remarkable how rapidly the common 



LOCAL REMEDIES. 439 

ulcer of the leg begins to improve in appearance as soon as the patient 
has taken a warm bath, simply applied a wet compress to the ulcer, 
and remained in bed quietly for twenty-four hours. The ulcer, which 
previously looked dirty or grayish-green, and had a pestilent odor, 
looks quite differently ; it has a tolerably fair if not very actively gran- 
ulating surface, and secretes good pus ; a fortnight's rest and great 
cleanliness sometimes suffice for a perfect cure of small ulcers of this 
kind. But the patient is hardly dismissed, and in his old mode of 
life, before the cicatrix again opens, and, in a few days, his condition 
is as bad as ever. So it goes on : the patient again enters the hos- 
pital, and is again dismissed, to be again received in a short time 
We have, however, some means of protection against these relapses, 
of which we shall speak hereafter. All ulcers are not inclined to heal 
so quickly ; many require various remedies and a long treatment. We 
shall now run through the various forms, according to their local 
symptoms, and mention the local remedies to be employed. 

1. The ulcer with inflamed borders, and the erethitic ulcer. Fre- 
quently, while the patient is constantly going about, an ulcer ap- 
pears very red and painful, and, after a period of rest, this slight 
amount of inflammation spontaneously subsides. But there are other 
ulcers whose borders are constantly red and sensitive, the ulcer bleeds 
easily, and the granulations are painful to the touch. Such ulcers are 
called erethitic or irritable / the highest grades of erethism of the 
surface of the ulcer are very rare ; in Zurich, I had a patient, who, as 
a sequent of a severe inflammation in the thigh, lost a large portion 
of skin by gangrene ; after the detachment of the eschar, there was 
left a very luxuriantly proliferating, granulating surface, with little 
tendency to heal, which was so painful to the lightest touch that the 
patient would cry out and shrink away. The cause of this excessive 
sensitiveness in such cases has already been mentioned when speaking 
of nerve cicatrices. 

In treating inflamed and erethitic ulcers, we first try mild salves 
of fresh butter and wax, unguentum cereum, then so-called cooling 
salves, such as those of zinc and lead, also fomentations with lead- 
water ; if under this treatment the granulations continue painful and 
look badly, while the inflammation of the surrounding parts is less, 
we may cauterize the surface of the ulcer freely with nitrate of silver, 
or, still better, with the hot iron ; the latter remedy, with subsequent 
compression by adhesive plaster, finally caused healing in the case 
above mentioned. In such cases, the local employment of narcotics 
is usually recommended, such as cataplasms, with the addition of bel- 
ladonna, hyoscyamus, opium, etc., but these remedies do so very little 
good, that, in my opinion, their employment is only time lost. 



440 



ULCERS. 



2. Fungous ulcers, i. e., those whose granulations are fungous and 
proliferating, and project above the level of the skin. These ulcers 
secrete a muco-pus, and are very vascular. 



Fig. 73. 



$Mm^m 




Blood-vessels of two luxuriant granulations of a common (not cancerous) ulcer of the leg, arti- 
ficially injected by Thiersch (Epithelial cancer, Plate XI., Fig. 4). 



In these cases we may use astringent remedies and compresses wet 
with decoction of Peruvian or oak bark, but they are of only moderate 
benefit. It is best to destroy the surface of such granulations by caus- 
tics; daily applications of the solid stick of nitrate of silver usually 
suffices, where it does not, we may resort to caustic potash or the hot 
iron. Compression with adhesive plaster is often very efficacious. 

3. Callous ulcers are most dreaded by surgeons, on account of 
the long treatment they require ; they are those whose base, edges, 
and vicinity, have become thickened and of cartilaginous hardness, 
from the long duration of chronic inflammation. The ulcer is torpid, 
and usually lies deep below the surface; the edges are sharply 
bounded. The indications for treatment are twofold : first, to soften 
the tendinous, non-vascular tissue of the hardened borders and base 
of the ulcer ; and to induce a proper amount of vascularity in these 
parts. We meet ulcers of this variety that have lasted twenty 
years or more ; in such cases we may employ the following treat- 
ment : compression, best with strips of adhesive plaster applied in a 
certain way, as you will see done in the clinic. This dressing, which 
should cover not only the ulcer but the entire leg, may at first be left 
on a day or two, but later, when the ulcer begins to heal, it may re- 
main untouched for three or four days, or longer. This so-called 



CALLOUS ULCERS. 441 

Baynton dressing of adhesive plaster is of great service in ulcers oi 
the leg, especially for those cases where the patients are not inclined 
to lie still, but must attend to their business. In the surgical poli- 
clinic of Berlin I made some observations on this treatment of ulcers 
of the leg, but cannot report so favorably on it, as a means of cure, 
as has been done by other surgeons — they seem to claim that this 
dressing is an almost universal remedy in ulcers of the leg. I prize 
it greatly as a protective dressing in dispensary practice, because it 
enables the patient to go about, without the ulcer spreading ; but I 
cannot see that all ulcers heal particularly well under this dressing, or 
that the action of the adhesive plaster on the callous borders of the 
ulcer is more effective than the remedies which I shall mention after 
a while. The best remedy for keeping up constant congestion in the 
ulcer, and thus increasing the formation of vessels and cells, is moist 
warmth, which you may use in the form of cataplasms, or, still better, 
as a continued warm-water bath. I would particularly recommend 
the latter to you, for by it you at the same time obtain an artificial 
swelling and softening of the dry, hardened borders of the ulcer. 
Zeis, who has often employed the warm-water bath in callous ulcers 
of the leg, also recommends this treatment as one of the most effi- 
cacious in such cases. It is sometimes very important to destroy the 
callous edges entirely, or to excite in them a high degree of purulent 
inflammation. The former you may most quickly accomplish by the 
hot iron, the latter by repeated application of tartar-emetic ointment 
or emplastrum cantharidis. If a pustulous or even gangrenous inflam- 
mation of the ulcer and its vicinity be induced by the latter reme- 
dies, place the foot in a water-bath and you will often obtain a very 
quick cure. 

It is not always possible to obtain healing of a callous ulcer of 
the leg ; and ulcers along the anterior face of the leg, extending to 
the periosteum of the tibia, are especially intractable ; those ulcers also 
which surround the leg like a ring are usually reckoned as incurable ; 
they are considered as indications for amputation when they perma- 
nently prevent the patient from walking or attending to his business. 
Besides the above-mentioned circumstances there is still another, that 
impedes the healing of ulcers with greatly-indurated borders, that is 
that the healing granulating surface and cicatrix do not diminish and 
thicken by contraction, because the firmness of the surrounding por- 
tions of skin permits no displacement ; while, as you know, all granu- 
lating wounds decrease to about half their size by contraction, and 
hence the cicatizing surface grows smaller, in many cases the granu- 
lating surface of these ulcers must cicatrize throughout its entire ori- 
ginal extent, because it cannot contract. To render this contraction 



442 ULCERS. 

possible, deep incisions have been made through the skin around the 
ulcer, and these incisions have been kept open by the introduction of 
charpie ; I have never seen any great benefit from this treatment. 
As a consequence of the rigidity also, the new cicatrix is not suffi- 
ciently dense and readily reopens, so that the ulcer once healed soon 
develops again. To guard against this it is best to cover the cicatrix 
with wadding and apply a starch-bandage. This dressing should be 
worn six or eight weeks, till the cicatrix is firm and well organized. 
I have followed this practice for a long time in all cases of ulcer of the 
leg, and have every reason to be satisfied with it. 

4. Suppurating ulcers. The causes of decomposition taking 
place on the surface of an ulcer are often due to unfavorable ex- 
ternal circumstances ; but, in other cases, from constitutional causes, 
there is a tendency to more rapid disintegration of the tissue on the 
surface of the ulcer. Solution of chloride of lime, pyroligneous acid, 
turpentine, spirits of camphor, and carbolic acid, are the remedies to 
be applied in such cases. If the destruction of the tissue go on very 
rapidly, so that the ulcer enlarges greatly from one day to another, it 
is called an eating or phagedenic ulcer ; this form closely resembles 
hospital-gangrene above mentioned. In some cases sprinkling pow- 
dered red precipitate of mercury quickly arrests the disintegration ; 
should it not do so, I would advise not to postpone the destruction of 
the entire ulcer ; free cauterization with caustic potash or the hot iron, 
destroying the edges of the ulcer down to the healthy tissue, almost 
always proves effective in these cases. 

5. Sinuous and fistulous ulcers — ulcers with excavated edges and 
fistulas. They always begin as abscesses, which gradually break 
through from within outward, and are particularly apt to depend on 
chronic suppuration of lymphatic glands. Such an ulcer will always 
heal more rapidly if you make an open ulcer of it, by cutting away 
the edges of skin, which are usually thin and undermined, or, if they 
are too thick for you to do this, at least split up the cavity and expose 
the deeply-seated ulcer. This treatment also answers for fistulous 
ulcers when they lead to abscesses ; the latter must heal before the 
fistula can close firmly. Let me remark, in parenthesis, the word 
" fistula " has still another meaning, as it is applied to any tube-like 
abnormal opening that leads to any cavity of the body ; thus we 
speak of breast, brain, gall-bladder, intestinal, vaginal, urinary, ure- 
thral, and other fistulas. 

We have still to consider a very important part of the chapter on 
ulcers, viz., the etiology, I have already told you that we have to 
distinguish local and constitutional causes, just as in chronic infiam- 



CAUSES OF ULCERS. 443 

mation. Hence all the causes that induce chronic inflammation are 
again to be enumerated here ; we will call particular attention to a 
few of these. If we first consider more carefully the local causes of 
ulcers, the most important of them is continued mechanical or chemi- 
cal local irritation. Continued friction and irritation are frequent 
causes of such irritable ulcers ; a tight boot, the hard edge of a shoe, 
may induce ulcers on the feet ; a rough tooth or a sharp piece of tar- 
tar may cause ulcers of the mucous membrane of the mouth or tongue, 
etc. Ulcers of this variety usually bear the marks of irritation ; the 
vicinity is red and painful, as is the ulcer itself. Among the chemical 
irritants we have the action of schnaps and rum on the gastric mucous 
membrane ; as a rule, topers have constant gastric catarrh, during 
whose course catarrhal and specific ulcers, of various kinds, not unfre- 
quently form. A second and still more frequent cause of chronic 
inflammation, resulting in ulceration, is congestion, especially venous 
congestion, distention of the veins, varicose veins. These are very 
intimately connected with the origin of ulcers of the leg; we shall 
speak of them later (Chapter XIX). There we will only mention that, 
as a result of the continued distention of the small cutaneous veins, 
there is chronic serous infiltration of the skin, to which is gradually 
added cellular infiltration, thickening ; and, lastly, there are frequently 
suppuration and disintegration. 

Ulcers due to varices, which are generally briefly termed varicose 
ulcers, may have very varied characteristics. At first they are ordi- 
narily simple, often proliferating ulcers ; subsequently they assume a 
more torpid character, and then the borders become callous. We have 
already noticed how quickly such ulcers change when they are only 
treated by rest and cleanliness. In regard to treatment, the already- 
lauded dressings with adhesive plaster are excellent both for inducing 
healing of the ulcer and arresting further development of the varices. 
But in most cases I prefer rest in bed, on the principles above given, 
and only subsequently apply the adhesive plaster to prevent further 
increase of the varices. 

Although we have here shown the intimate relations between 
varicose veins and ulcers, and have thus called attention to the point 
of greatest practical importance about this disease of the veins, you 
must not conclude that varices are always followed by ulceration ; on 
the contrary, there are many cases of enormous varices that are not 
followed by secondary ulcers. 



We come now to a short description of those ulcers that are due 
to internal causes, and are connected with various dyscrasia — the 
symptomatic ulcers. 



444 ULCERS. 

1. First among these are scrofulous ulcers ; these most frequently 
come m the neck, enclosed collections of pus developing in the cutis 
or subcutaneous tissue, and gradually perforating out through the 
skin. Of course, this causes small losses of skin, whose edges are 
usually red and very thin, and which lead to deeply-seated cavities 
that evacuate thin pus or tissue that has undergone caseous degen- 
eratiou. The borders of these cutaneous ulcers are excavated, as may 
readily be shown by examining with the probe. As a rule, these are 
typical atonic ulcers. From this description you see that this form of 
undermined sinuous ulcers is only due to the mode of origin, and may 
occasionally present itself under the most varied constitutional con- 
ditions ; although experience teaches that it is especially frequent in 
scrofulous persons, and this is why such atonic ulcers with under- 
mined edges are referred to scrofula. This conclusion will generally 
prove correct, though it is not necessarily the case. 

2. Lupous ulcers. By lupus we understand a disease which 
manifests itself by the development of small nodules in the superficial 
layer of the skin. The subsequent progress of these nodules may 
vary. They consist of collections of wandering cells and coincident 
ectasia of the vessels. Lupous nodules may (a) enlarge and run 
together, so as to form larger nodules and tuberculous thickenings of 
the skin (Lupus hypertrophicus) ; (b) on their surface there is a free 
exfoliation of epidermis (Lupus exfoliatus) / (c) the surface ulcerates 
(Lupus exulcerans). All three forms may combine, and some others 
may be added to them. The ulcers resulting from the latter form may 
be accompanied by strongly proliferating granulations (Lupus exul- 
cerans fungosus), or dispose to a more rapid destruction of tissue 
(Lupus exedens, vorax). The disease is most frequent on the face, 
especially on the nose, cheeks, and lips ; it causes the most frightful 
disfigurement. The nose or the lips may be entirely destroyed by 
lupus. I saw one case where all the skin of the face, nose, lips, and 
eyelids, was destroyed ; both eyes had been lost by suppuration, and 
the facial part of the skull, being exposed, presented a most horrible 
sight. Lieffenbach describes such a case in a Polish count, and com- 
pares his appearance to that of a death's head. Lupous ulcers do 
not by any means always look alike ; but their surroundings, and the 
general appearance of the portion of skin diseased, greatly facilitate 
the diagnosis. When lupus occurs in other parts of the body, as in the 
extremities or mucous membranes, as the throat or conjunctiva, the 
diagnosis is difficult, and cannot always be made positively. It is not 
only pardonable, but sometimes unavoidable, to mistake the disease 
on the extremities for certain forms of leprosy, and in the throat for 
syphilitic ulcers. In most cases lupus is due to a dyscrasia. It is 



LUPUS. 445 

rarely a purely local skin-disease. It is doubtful whether we are jus- 
tified in claiming a particular lupous dyscrasia, for lupus very often 
attacks scrofulous persons, so that it may be regarded as one, and one 
of the worst symptoms of scrofula. It also comes as one symptom of 
syphilis, so that lupus syphiliticus and lupus scrofulosus are spoken 
of. Lupus is most frequent during puberty, and attacks females 
oftener than males ; it more rarely develops late in life ; beyond the 
fortieth year we are pretty safe from it. 

In the way of treatment I attach most importance to local treat- 
ment, especially in the ulcerative form, for here we must make every 
attempt to arrest the progress of destruction, which may endanger all 
the skin of the face, and internal remedies act very slowly. Here, as 
in all rapidly-spreading ulcerations, we should radically destroy the 
base and edges of the ulcer by cauterizing down to the healthy tis- 
sue. We generally employ the potential cautery and the solid stick 
of nitrate of silver or caustic potash, pushing them through the lupus 
into the healthy parts below. We may also use the caustic in the 
form of paste, such as chloride-of-zinc paste, which is most readily 
made by mixing chloride of zinc with rye or wheat flour, and making 
it into paste with a few drops of water, then spreading it on the ulcer. 
To attain our object more rapidly, and let the caustic act more in- 
tensely, it is advisable to scratch up the floor of the ulcer with the 
flat end of a probe, and, after arresting the bleeding, apply the caus- 
tic. Of the remedies above mentioned, I prefer caustic potash, as it 
unites with the tissues most rapidly, and consequently the pain ceases 
sooner. This cauterization may be done during anaesthesia, so that 
when the patient awakes there will be a moderate and tolerable burn- 
ing. Nitrate of silver causes the most protracted suffering, but has 
the advantage of liquefying less rapidly than caustic potash, and hence 
possesses special advantages for cauterizing some portions of the 
body. When the slough from the cauterization is detached, if the 
operation was thoroughly done, there is left a good granulating sur- 
face, which cicatrizes in the ordinary manner. A new lupus is not 
apt to form in this cicatrix, although cauterization cannot prevent the 
development of new nodules in the vicinity. Painting with tincture 
of iodine is the best local remedy in exfoliative and hypertrophic 
lupus. It is well to mix this remedy with glycerine, to render its ac- 
tion less intense. I have repeatedly seen lupus nodules shrivel up 
under this treatment, but it does not prevent relapses. Lastly, in 
some cases, the portion of lupous skin may be excised with advan- 
tage. The only internal remedy from which I have seen benefit is 
cod-liver oil, of which four to six table-spoonfuls are to be given daily, 
but this treatment must be continued for years. Decoctions of barks 



446 



ULCERS. 



are only useful in lupus syphiliticus. Arsenic, which is highly prized 
in other chronic skin-diseases, is of little use in lupus. In Switzer- 
land the disease was rare. My experience of it was chiefly derived in 
the Berlin clinic, and, if I were to state my belief regarding the effi- 
cacy of internal treatment, it would be to the effect that the lupous 
dyscrasia, like the scrofulous, often disappears spontaneously in the 
course of time, but is also often incurable. 

3. Scorbutic ulcers. Scorbutus, or scurvy, is a disease which, as al- 
ready stated, when fully developed, manifests itself by great weakness 
of the capillary vessels. There are extravasations of blood at many 
places in the skin and muscles ; the gums swell, become bluish red, 
and ulcers, which bleed readily, form on them ; there are also intes- 
tinal haemorrhages, general emaciation and debility, and many patients 
die in a miserable state. This severe form of scorbutus occurs chiefly 
endemically on the coasts of the Baltic, and in sailors on long voy- 
ages. In the latter case the disease is usually referred to continued 
use of salt meat. Inland there is a sort of acute scorbutus, comprising 
morbus maculosus, purpura, etc. Scorbutus localized on the gums 
and oral mucous membrane is everywhere common among children ; 
the gums swell, become of a dark bluish red, bleed on the least touch, 
and ulcers, covered with a yellow, smeary coating of pus, fungi, and 
shreds of tissue, form on them. When the disease appears in this 
form, and is treated early, it is generally readily cured. You should 
paint the gums twice daily with a mixture of half a drachm to one 
drachm of muriatic acid and an ounce of honey ; internally administer 
mineral acids in dose and form suited to the age, and order a light, 
easily-digested diet. If this treatment be conscientiously followed, 
the disease soon disappears. General endemic scorbutus is difficult to 
cure, because it is generally impossible to withdraw the patients from 
the injurious endemic influences. In this also the acid treatment is 
greatly recommended. 

4. Syphilitic ulcers. The marks that are usually given, as particu- 
larly characteristic of syphilitic ulcers, refer almost exclusively to the 
primary chancre, especially the soft chancre. This begins as a ves- 
icle or pustule, develops to an ulcer as large as a pea, with red bor- 
ders and a yellow, fatty-looking base. The ulcer of the indurated 
chancre looks differently; in this there is first a nodule in the mem- 
brane of the glans or prepuce. This nodule ulcerates from the sur- 
face, as other cutaneous ulcers do. It usually assumes an atonic, 
torpid character, frequently with a marked tendency to breaking down 
of the tissue. Broad condylomata, one of the milder evidences of 
constitutional syphilis, are, strictly speaking, nothing but small, su- 
perficial, very circumscribed fungous cutaneous ulcers, which occur 



SYPHILITIC ULCERS. 447 

most frequently on the perinaaum, about the anus, and on the tongue. 
The so-called tertiary syphilitic ulcers of the skin often have very in- 
durated, brownish-red borders, are circular, or horseshoe-shaped, and 
are also atoDic in character. You will see from this that the appear- 
ance of syphilitic ulcers also may vary greatly, and hence that the 
mere appearance of the ulcer does not enable us to judge with cer- 
tainty of the presence of constitutional syphilis. The treatment 
of true syphilitic ulcers should be chiefly internal, and be directed 
against the constitutional disease. Locally we should use intense 
caustics if the destruction of tissue is going on rapidly. 



Older surgeons also distinguished numerous forms of ulcers that 
have not been mentioned here, and that were said to be characteristic 
of the causes. For instance, in his treatise on ulcers (Helkologie) 
Must speaks of rheumatic, arthritic, haemorrhoidal, menstrual, abdom- 
inal, herpetic, etc., ulcers. But I, in common with other surgeons of 
modern times, have been unable to penetrate into the mysteries of 
this exact diagnosis. It is now generally considered that the old no- 
menclature was based rather on an artificial system originating in the 
old humoral pathology than on critically exact observation. From 
unprejudiced observation we should unquestionably acknowledge that 
certain forms of ulcers, particularly when affecting certain localities, 
enable us to decide on their cause ; nevertheless, the appearance and 
form of the ulcer are very dependent on the anatomical relations of 
the part affected (e. g., as by the course of the filaments in the skin, 
Wertheim), and on various external causes, so that we should fre- 
quently be deceived if we relied too much on the appearance of the 
ulcer as an unmistakable expression of a specific constitutional cause. 



CHAPTER XYI. 

CHRONIC INFLAMMATION OF THE PERIOSTEUM, 
OF THE BONE, AND NECROSIS. 



LECTURE XXXII. 



Chronic Periostitis and Caries Superficialis. — Symptoms. — Osteophytes. — Osteoplastic, 
Suppurative Forms. — Anatomy of Caries. — Etiology. — Diagnosis. — Combination 
of Various Forms. 

Geistlemen" : Chronic inflammations of the bones and periosteum, 
to which we now pass, are far more frequent than the acute forms ; 
the more common disease is chronic periostitis, which is often accom- 
panied by ostitis (caries) superficialis. In the early stages this may 
end in resolution, then go on to suppuration, with ulceration of the 
surface of the bone ; it may also be accompanied by a deposit of 
newly-formed ossific substance on the surface of the bone. Perios- 
titis that has lasted some time will never leave the bone unaffected. 
Let us first consider the symptoms of chronic periostitis. The first 
symptoms are usually slight pain, and moderate swelling of the parts 
immediately around the affected bone. These are accompanied by 
slight functional disturbances, especially when the disease is in one 
of the extremities. Spontaneous pain is usually slight, or may even 
be entirely wanting. Pressure induces severe pain, and we find that 
the impress of the finger remains evident on the skin for some time, 
showing that the swelling of the skin is chiefly cedematous. The dis- 
ease may remain for a long time in this stage, and may subside as 
gradually as it began. In such cases you may consider the affection 
as located in the external loose connective tissue of the periosteum. 
Here there is distention of the vessels, serous and plastic infiltration. 

The symptoms above given may also depend on a periostitis com- 
bined with a superficial ostitis, only in the latter case the spontaneous 
pains are occasionally more intense ; there are also severe, boring, 



PERIOSTITIS. 449 

tearing pains at night. If such a process has lasted for months and 
then recedes, the affected bone remains thickened and nodular on the 
surface. If you have a chance to examine such a case anatomically, 
you find the following : The two layers of the periosteum cannot be 
exactly separated ; both have changed to a fatty-looking, tolerably- 
consistent mass. On microscopical examination you find that the tis- 
sue consists of connective tissue richly strewn with cells and traversed 
by dilated capillaries in greater or less number. This morbidly-thick- 
ened periosteum is more readily detached from the surface of the bone 
than is normally the case ; the subjacent bone (we are supposing a 
hollow bone, such as the tibia) has its surface covered with small 
nodules of peculiar, occasionally stalactite shape. If you now saw 
through the bone, you find that these nodules on the still-distinct sur- 
face of the compact cortical substance are a thick layer of porous, 
apparently young, newly-formed bone-substance, which are very inti- 
mately connected with the cortical substance, it is true, but which, 
nevertheless, if the process be not too old, may be broken off with a 
chisel in good-sized pieces. If the disease has already lasted some 
time, and the union has become very intimate, we find that the de- 
posited porous bone has become more compact, especially if the mor- 
bid process has actually terminated. 

Let us stop here a moment to inquire the origin of this newly- 
formed bone. It may come either from the inner surface of the 
periosteum, or from the surface of the bone. The former is the gen- 
erally-received opinion, and it is supposed to be a renewal of the 
function of the periosteum, as it existed before the bone had com- 
pleted its growth, when regular layers of new bone were always 
formed on the inner surface of the periosteum. This form of perios- 
titis, which is combined with the formation of osteophytes (as the 
young bony substance deposited during inflammation is termed), may 
be called osteoplastic, a name which I shall use, for the sake of brevity. 
Nevertheless, I do not agree in the above view, that osteophytes pro- 
ceed solely from the periosteum, but am satisfied that they actually 
grow from the bone, as the Greek name indicates. For, microscopic 
examination shows that, in this case also, as in suppuration and gran- 
ulation on the surface of the bone, the small vessels that enter and 
escape from the bone with their enveloping connective tissue are the 
seat of the new formation, which advances from the Haversian canals 
opening on the surface of the bone, and are the point of origin for 
the new formation of bone, which then spreads out under the perios- 
teum. These ossifying granulation-nodules grow from within out- 
ward somewhat into the periosteum, and then the latter takes a 
secondary part in the process, as it seems to me. The form of the 
29 



450 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

osteophytes, which is often peculiar, depends on the arrangement of 
the vessels around which the young osseous material is deposited. 
We would not by any means assail the undoubted fact that the peri- 
osteum, and other parts adjacent to the bone, may also produce new 
bone, still I assert that, correctly viewed, osteoplastic periostitis is an 
osteoplastic ostitis superficialis. This subtle distinction has no prac- 
tical value, so far as we now know. Osteophytes are the product of 
an inflammatorg irritation of the periosteum and surface of the 
bone ; they are precisely what we call callus, in fractures, and they 
are formed in the same way. I here remark that periostitis, accom- 
panied only by formation of osteophytes, without any suppuration, is 
especially peculiar to some forms of constitutional syphilis. The 
dolores osteocopi, which may be so torturing in the head and shin- 
bones, in tertiary syphilis, are almost always due to osteoplastic 
periostitis and ostitis. 

According to my experience, almost every chronic periostitis is at 
first osteoplastic ; all other terminations follow it more or less closely. 
The suppurative form is also very frequent ; it may run its course 
without the bone being much affected. Recall the symptoms already 
mentioned : cedematous swelling of the skin, pain on deep pressure, 
and a slight amount of it on moving the limb. This condition re- 
mains long the same, but is gradually followed by more swelling, by 
an immovable, doughy tumor, not perfectly but still tolerably well 
defined. By degrees the skin reddens, and the tumor fluctuates de- 
cidedly. Four to six months may thus pass, and then the tumor 
remains for a long time unchanged. The pain has probably increased, 
and the function is more disturbed. If the disease be left to itself, 
the cold abscess, which now evidently exists, will open, and a thin pus 
mixed with flocculi or cheesy substance will escape. If, through the 
fine opening, you pass a probe, it will enter a cavity lined with gran- 
ulations. If you do not wait for the spontaneous opening of the 
abscess, but make an incision through the thin skin, it is possible that 
no pus may escape, but that you will find the fluctuating tumor to 
consist of a gelatinous mass of red granulations ; in other cases there 
is some pus in the centre of the swelling ; in still others the entire 
tumor is of pus. From what I have already told you of the anatom- 
ical conditions in chronic inflammation, you will readily understand 
these different states. If, in the periosteum, infiltrated with serum 
and plasm, you imagine a rich development of vessels, and at the 
same time an infiltration of wandering cells, and transformation of the 
connective tissue to a gelatinous intercellular substance, the former is 
metamorphosed to a spongy mass of granulations. This may sooner 
or later change to pus, and an abscess is the final result. If the whole 



PERIOSTITIS. 



451 



Fig. 74. 



process affects only the periosteum and superjacent soft parts, the 
bone is but little changed ; some inclination to new formation is ex- 
hibited on its surface by the production 
of a layer of osteophytes under and in 
the periphery of the part affected with 
periostitis. Nevertheless, there is a 
possibility of the abscess healing slow- 
ly, after the pus has been evacuated, 
and of a return to the previous normal 
state. Such a recovery of periostitis, 
without implication of the bone, occa- 
sionally occurs in practice, but it is rare. 
It is far more common for the bone to 
be also affected, perhaps only super- 
ficially; that is, for periostitis to be 
accompanied by ostitis ; not an ossify- 
ing, but a chronic, suppurative, ulcer- 
ative ostitis — a caries superficialis. 
Before the abscess has opened, the 
symptoms of such a caries scarcely dif- 
fer from those of suppurative perios- 
titis. If the abscess has opened, we 
may pass a probe into the surface of 
the bone, which we feel to be rough 
and gnawed. The caries had existed 
some time, and was secretly eating into 
the bone before the abscess opened; 
it probably existed when the perios- 
teum only appeared infiltrated, and 
was still in the stage of gelatinous 
granulation. Hence, suppuration is 
not necessarily combined with caries, 
although it frequently accompanies it. 
To make all this clear to us, we must 
study chronic ostitis by means of prep- 
arations. The whole development and course are quite analogous to 
the course of chronic inflammation in the soft parts, but the hardness 
and difficult solubility of bone give rise to somewhat different circum- 
stances. 




Caries superflcialis of tne tibia, accord- 
ing to Follin. 



In the course of these lectures we have repeated time and time 
again that inflammatory neoplasia is developed in and from the 
affected tissue ; that the close connective-tissue filaments, by rich in- 



452 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

Hltration of cells, are transformed into gelatinous or even fluid inter- 
cellular substance. Now, how shall this be transformed into bone ? 
The cells embedded in the stellate bone-corpuscles participate no more 
in the inflammatory new formation than the stable connective-tissue 
corpuscles. Here also, as in most tissues of the body, the inflamma- 
tory neoplasia infiltrates the connective tissue ; namely, that which 
envelops the vessels in the Haversian canals, and in the medulla of the 
bone. Still, the space for the extensive production of cells is limited, 
and, if the wandering of the cells went on very rapidly, the vessel 
would soon be entirely compressed in the bony canal ; if the circula- 
tion be then arrested, the nutrition of the young brood of cells also 
ceases, and the necessary result is death of the affected portion of 
bone (necrosis). Quite right, this may be the course ; superficial ne- 
crosis may thus combine with periostitis ; of this hereafter. Usually, 
however, the cell infiltration in the Haversian canals is not so rapid as 
to compress the vessels. The process is chronic ; the bone gradually 
gives way, the Haversian canals become wider and wider, the firm 
cortical substance of the bone becomes porous, in the canals (widened 
to meshes) lies the brood of young cells, interspersed with gelatinous 
intercellular substance and numerous vessels, an interstitial prolifera- 
tion of granulations. If you imagine the process as continuing, the 
bone disappears more and more, the entire infiltrated portion may be 
dissolved, and the inflammatory neoplasm takes its place. If you 
macerate such a bone, at the seat of disease you will find a loss of 
substance, with rough porous walls, that look as if gnawed off; in this 
defect lies the neoplasia that has taken the place of the bone (Fig. 
74). Now, remember that so far the word pus has not been men- 
tioned ; still, of course, the inflammatory neoplasia may subsequently 
suppurate, and, if we continue our supposition that the process began 
in the periosteum, you have a superficial cold abscess lying on the 
bone ; its walls may be covered with granulations. 

If you have carefully followed me thus far, you will have remarked 
already that throughout the whole process the bone substance remains 
entirely passive ; it is entirely consumed, and we might say, with a 
certain amount of truth, chronic ostitis, or caries, is actually only a 
chronic inflammation of the connective tissue in the bone, with con- 
sumption of the latter. And according to my view this is perfectly 
correct, at least for the great majority of cases. Still, how does this 
consumption of bone take place ? Should not microscopical examina- 
tion show whether the bone-cells are changed or not during the pro- 
cess ? Remove with the forceps a particle of bone, as thin a sheet as 
possible, from a carious spot, and look at it under the microscope, 
you will in many cases see its edges and surface bitten out, as it were ; 



CARIES. 



453 



the bone-corpuscles are unchanged ; the intercellular substance some- 
what more cloudy than usual, perhaps, but not much altered ; a sec- 
tion of bone, taken from the vicinity of such a carious spot, shows 
nothing different. If you saw or cut out a piece from a carious spot, 
and abstract the chalky salts from the bone by chromic acid, and then 
make sections through it and clear them with glycerine, you will have 
about the following picture (Fig. 75) ; 



Fig. 75. 







Section of a piece of carious 'Done (caries fungosa). Magnified 350 diameters. 



These pieces of bone are often bitten out, as it were, quite regu- 
larly along their edges, the young neoplasia grows into these defects, 
their further increase goes hand in hand with the dissolution of the 
bone ; the bone-corpuscles are unchanged, no destruction starts from 
them, we occasionally see them half destroyed at the edge of a piece 
of the bone. What becomes of the cells that were in them, we can 
hardly say ; they can no longer be recognized among the numerous 
young cells of' the inflammatory new formation among which they 
enter ; it is possible that, freed from their cage, they aid in increasing 
the cell-brood by subdividing, possibly they die ; at all events, as far 
as may be judged by the change of form, they do not aid in dissolving 



454 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

the bone. But how the bone is dissolved remains an unsolved riddle. 
Living, like dead bone, may, to a certain extent, be dissolved by the 
interstitial bony granulation. Previously, when speaking of operating 
for pseudarthrosis by the insertion of ivory pegs, I told you, if you 
will remember (p. 229), that the ivory pegs became rough on their 
surface, carious ; there the process is just the same, and this observa- 
tion is exceedingly interesting and important as a proof that the bone 
itself does not necessarily have any thing to do with its solution in 
caries, but may play a perfectly passive part. To anticipate the charge 
that I admit only this variety of consumption of bone, where the above 
changes occur on the surface, I must add that I have already called 
attention to the fact that the ivory pegs introduced for pseudarthrosis 
do not always become rough on the surface, but might remain smooth 
and still lose substance, as may be shown by weighing them before 
and after the operation. The morphological appearances in the carious 
bone, which JR. Vblkmann very aptly designates lacunar corrosions, 
and which Howship first made known, are now generally recognized 
as correct, although different views were formerly held regarding them, 
which you may find in the cellular pathology of Virchow, and in 
Forstefs atlas, if the subject interests you. 

One point, however, we must consider. It would be very sup- 
posable that the bone-substance, having its nutrition affected, would 
begin to break up and crumble into very fine particles, or powder ; 
this would be especially apt to occur if the bone had previously lost 
its organic substance. It could even be shown that this is the primary 
step in ulceration of the bone, or caries, and those who regard destruc- 
tion of tissue as the primary step in ulcers of the soft parts, and in- 
flammatory new formation as the second, will also hold this view in 
regard to bone. As I have already stated, my observations speak 
very decidedly against the universality of this view of ulceration, and 
what I did not find proven as regards the soft parts, I cannot consider 
true as regards the bones. But there is no doubt that portions of 
bone may crumble off, and, when there is suppurative ostitis, these 
small particles of bone may be found in the pus. This would be a 
necrosis of the lowest form ; such a death of the particles of tissue 
also occurs in the soft parts, both in acute and chronic inflammation ; 
you will doubtless bear in mind that we have spoken of this subject. 
It cannot be considered as a rule in caries ; it is only seen occasionally 
in caries with suppuration or caseous degeneration. Here even large 
portions of bone may become actually necrosed, and for this combi- 
nation of caries and necrosis we have the curious name of caries 
necrotica. 

Thus far we have used the term caries as exactly synonymous with 



CARIES. 455 

chronic ostitis and solution of bone, and at present this is very gener- 
ally done ; but formerly the name caries was only used for ulceration 
accompanied by suppuration, for open ulcers of the bones. The inti- 
mate connection between chronic inflammation and ulceration, which 
we previously studied in the soft parts, also exists between chronic 
ostitis and caries. If you desire to designate the character of the 
inflammation more specifically, it may be done conveniently by certain 
additions which you already know from the chapter on ulcers. Per- 
haps it would be better to gradually drop the name caries and replace 
it by ostitis with various additions, such as rarefying, osteoplastic, 
ulcerating, granular, etc., or only to employ caries for bony defects 
caused by lacunar erosions. On macerated bones this is always readi- 
ly recognized ; there we are never in doubt as to whether the bone is 
carious, for we call carious all defects that look as if gnawed out ; 
they might very well be termed lacunar or corrosive defects. But on 
living patients it requires accurate knowledge and rich experience to 
decide certainly whether a bone which a sound enters readily is only 
softened or has large lacunar defects. Up to this point we have 
only studied superficial caries ; hereafter we shall come to central 
caries, which holds, the same relation to the superficial that the ab- 
scess does to an open ulcer. In the soft parts I showed you the de- 
velopment of the process of ulceration in a fungous ulcer, where the 
productive character predominates. This has its analogy in bone, in 
ostitis fungosa (by caries sicca, Virchow and Vblkmann mean caries 
with proliferating granulations and destruction of bone without sup- 
puration), where there is as yet no destruction of the inflammatorj' 
new formation, but where interstitial granulation-tissue has grown 
all through the bone. This does not by any means always occur to 
the extent we have just supposed. If you bear in mind the atonic, 
torpid ulcer of the soft parts, and remember how the neoplasia rapid- 
ly breaks down into pus, undergoes caseous transformation, or disin- 
tegrates, and simply apply the same changes to bone, you will readi- 
ly understand the case ; this also gives caries another character ; 
there are very torpid, atonic forms of caries where the neoplasia 
causes but little destruction of bone, and then disintegrates or under- 
goes caseous metamorphosis, and thus in the living organism there is 
a sort of maceration of the diseased bone ; the soft parts in the bone 
suppurate; if this happen before the bone is dissolved, the portion 
of bone that has suppurated is necrosed. Here, also, most of the 
fault of the disintegration is due to deficient vascularity. But we 
must look to constitutional influences for the causes why we have in 
one case fungous or proliferating, in another atonic caries. 

We shall become acquainted with other forms of ostitis when we 
come to speak of primary chronic inflammation in bones. 



456 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

Chronic inflammation of the periosteum and bone is chiefly due 
to constitutional, dyscrasial diseases ; and although injuries, blows, 
falls, etc., may be exciting causes of these diseases, the ultimate 
cause must lie in the injured part or the system at large, otherwise 
the process would take the course usual to traumatic inflammations 
and soon terminate. If an injury induces insidious chronic inflam- 
mation, this must be due either to a peculiar local or constitutional 
condition ; so far I have had no reason to abandon this opinion. 

Of the dyscrasise already known to you, the scrofulous and syph- 
ilitic especially predispose to chronic periostitis and ostitis ; among 
scrofulous children the fungous forms of caries are most frequent, 
while among adults the atonic occurs oftener. True tubercles are 
also found in bone, but, so far as I know, not in the periosteum or 
the cortical layer of the long bones. 

But chronic periostitis also occurs frequently when none of the 
above dyscrasiae are discoverable, and where we can recognize no 
cause ; in old people especially, periostitis with caries sometimes 
comes from very slight injuries, and runs its course in the most dis- 
agreeable torpid form. 

The inflammatory neoplasia in the bone will greatly sympathize 
if the general health fails ; in children who have died of caries, you 
will almost always find the atonic form, for, just previous to death, 
while the nutrition was bad, the neoplasia also broke down ; the dis- 
eased bone, even during life, was macerated by suppuration and 
mortification. Pathological anatomists, who only see caries on the 
dissecting-table, rarely know the fungous form accurately, or con- 
sider it the more rare ; but, when one often examines pieces of 
carious bone, cut out during life, especially the resected joints of 
children, where the process is going on actively, he learns to judge 
differently from what he would in the anatomical museums, where 
macerated bones, almost exclusively, are preserved. 

Although I have merely spoken of fungous and atonic caries, 
you still understand that I have only depicted the extremes of the 
proliferating and rapidly disintegrating new formation. Of course, 
there are many intermediate forms. 

It is not the object of these lectures to carefully delineate all the 
shades of this process, as will be done in the clinic, but here the pic- 
ture of diseases should be drawn from typical cases, you should ac- 
quire a mental mastery of the subject ; hence I only lead you so far 
into the details of the process as is necessary for understanding its 
anatomy. 

Now you will very justly ask, How shall we know whether the 
case, which we have only diagnosed with the probe, be of the pro- 



CAKIES. 457 

liferating or torpid variety ? This will have an influence on the 
treatment, as it has in case of ulcers of the soft parts. And it is im- 
portant not only for the treatment, but for the prognosis ; for pure 
torpid caries offers far poorer chances than the fungous form, be- 
cause it is far more apt to occur in poor, badly-nourished, and old 
persons. The distinction is not difficult. In the more proliferating 
forms, the swelling of the soft parts, periosteum, and skin, and espe- 
cially of the articular capsule when the caries affects the articular 
ends of the bone, is often considerable ; all these parts feel spongy. 
If there be any openings in the skin, proliferating granulations pro- 
ject from them, and a mucous, tough, synovia-like pus escapes. If 
you examine with the probe, you do not come at once on bare bone, 
but must push the probe into the granulations, often to some depth, 
before entering the rotten bone. 

In the pure atonic form there is less swelling, the skin is thin, 
red, and often undermined. The edges of the opening are sharp, as 
if cut out with a punch ; there is a discharge of thin, serous, some- 
times badly-smelling or sanious pus ; if you introduce the probe, you 
come at once on the bare, rough bone, from which the soft parts have 
already been separated by suppuration and maceration. These are the 
extreme cases of the series ; there are various intermediate forms. 

Taking all things into consideration, I think you will now have a 
correct idea of caries superficialis. 

Let us make a short review of what we know of chronic diseases 
of the periosteum and bone. We have considered chronic osteo- 
plastic periostitis (with formation of osteophytes without suppura- 
tion), suppurative periostitis alone, and combined with ostitis superfi- 
cialis, or caries. But osteoplastic periostitis may combine with caries, 
and this combination is even frequent, i. e., osteophytes form round a 
carious point in the bone. If you examine a series of preparations of 
carious joints, you find the osteophytes starting from the surface of 
the bone, around the destroyed portion ; the periostitis, which at one 
place induced destruction of the bone, caused formation of new bone 
in the vicinity. You may very aptly compare this to an ulcer with 
callous edges — thickening by new formation in the periphery, de- 
struction in the centre. But we do not have formation of osteophytes 
at the periphery in atonic forms of caries ; it only occurs in those 
which, at least for a time, bore a proliferating character ; just as in 
torpid, scrofulous ulcers you only find thickened edges where the skin 
had for a long time been thickened by plastic infiltration, so in the 
bone also we have this combination of proliferation and destruction 
which we have so often met in the study of inflammation. 



458 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 



LECTURE XXXIII. 



Primary Central, Chronic Ostitis, or Caries. — Symptoms. — Ostitis Interna Osteoplas- 
tica, Suppurativa, Fungosa. — Abscess of Bone. — Combinations. — Ostitis with Ca- 
seous Metamorphosis. — Tubercles of Bone. — Diagnosis of Caries. — Dislocation of 
the Bones after their Partial Destruction. — Congestion Abscesses. — Etiology. 



Hitherto we have only treated of chronic ostitis in so far as it is 
dependent on periostitis. This is almost always the case in the hol- 
low bones, for in them the cortical layer is not much disposed to be- 
come primarily diseased. The case is different with the spongy bones 
and bony parts ; in them a chronic inflammation may arise indepen- 
dently, just as in the medullary cavity of a hollow bone there may oc- 
cur a circumscribed chronic osteomyelitis, so that the cortical substance 
may become diseased from within. These cases are designated as 
ostitis interna or caries centralis. The symptoms of such a chronic 
inflammation, occurring deep in the bone, are in many cases very un- 
decided. A dull, moderate pain, and a consequent slight impairment 
of function, often form the only symptoms. Swelling comes on later, 
and the disease may exist for months before we can form a certain 
diagnosis. But when we find severe pain on pressure, and oedema of 
the skin, and the periosteum participates secondarily in the chronic 
inflammation, we shall gradually be led to the correct diagnosis, the 
more readily if the disease be circumscribed, and perforation finally 
takes place, so that we may pass a probe through the opening deep 
into the bone, and find exactly what is the state of affairs. In many 
cases periostitis is for a long time the chief symptom of ostitis ; the 
former may be so prominent that it appears to be the only disease, 
till, from the long duration, and from losses of substance from within, or 
lastly, perhaps, even by detachment of small pieces of bone, attention 
is called to the fact that the continued suppuration is due to disease 
deep in the bone. It has already been stated that chronic inflamma- 
tion in bone first shows itself by the chalky salts becoming soluble. 
So far we have only studied cases where the disease was circum- 
scribed and progressed inward from the surface. Now, imagine an 
ostitis developing in a spongy bone, as one of the tarsal bones, or in 
the diaphysis of one of the long bones, as in the lower part of the 
tibia, and the chalky salts disappearing from the bony tissue while 
the vessels of the medulla increase, and the medulla, infiltrated with 
wandering cells, gradually takes the place of the disappearing bony 
tissue. Here we have the picture of a pure ostitis malacissans, an 
osteomalacia inflammatoria or rarefying ostitis ( Volkmann). In this 



OSTITIS MALACISSANS. 



459 



affection the bones become very light, and the cortical substance 
very thin. 

Mindfleisch has shown how the atrophy occurs in such cases ; for 
he discovered that the chalky salts were first dissolved and disap- 
peared as in lacunar corrosion. But while in the latter case the 
osseous tissue disappeared with the chalky salts, in the present case 
the tissue continues to exist for a time ; the cases where every trace 



Fig. 75 A. 




Ostitis malacissans : a, vertical section of the calcaneus, diseased anteriorly and posteriorly, normal 
in the middle ; b, vertical section of the upper end of the tibia, quite porous. 

of bone inside the periosteum has disappeared in this way, show that 
the osseous tissue which has lost its salts is finally absorbed itself. 
But whether this is always the case, or whether it ma}^ again be im- 
pregnated with chalky salts and again become normal bone, is not 
known. Whether this variety of atrophy, which may correctly be 
termed halisteresis ossium (from a/lc, salt, and (jreprjatg, robbing, 
Kilian), always runs the course shown in Fig. 76, is not fully inves- 
tigated ; possibly the chalky salts and the tissue might be absorbed 
at the same time. The fact that there is no sign of proliferation in 
the bone corpuscles of the tissue deprived of its chalky salts seems 
to prove that they are not disposed to proliferate. 

So we have here a form of inflammation of bone in which its 
atrophy is a particularly prominent feature, and there is a very 
scanty formation of osteophytes, or this may be altogether absent. 
In the bone there is no regenerative process ; the medulla, which is 



460 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

reddened from the great vascularity, usually contains fat, but is 
richer in young cells than the medulla of the bones of adults usually 
is, and hence more resembles the condition in childhood. The ostitis 
malacissans may remain in this state ; should it slowly progress, it 
would lead to complete solution of the bone, till only medulla and 
periosteum remain, and the bone is so soft as to yield to any trac- 



Fig. 76. 




Disappearance of the chalky salts from the peripheral portions of the o&seous framework in ostitis 
malacissans. Magnified 350. After Rindfleisch. 



tion or pressure ; but this is rare. According to my experience, it is 
just as rare for the medulla in these bones to suppurate or become 
caseous without some external cause ; but this is sometimes induced 
by violent probing, dirty probes, bruising, or operations. Mild cases 
of this form of ostitis may recover by formation of new bone in the 
cavities of the old bone ; while severe cases in marasmic patients are 
incurable and require amputation. 

Ostitis osteoplastica is just the opposite of the above ; we do not 
how whether the disturbance of nutrition by which it is started also 
begins with loss of chalky salts from the bone ; the main effect of the 
disturbance is abnormal formation of new bone in the medulla and 
in the Haversian canals. When the disease occurs in the long bones, 
it generally attacks the whole bone at once, and even affects several 
bones at the same time. The result of this disease may be the com- 
plete filling of the medullary cavity, with a tolerably compact bony 



SCLEROSIS OF BONE. 



461 



mass, the almost complete filling of the Haversian canals with bony sub- 
stance, and generally also the for- 
mation of bone on the surface. Fio.77. 
Thus the entire bone becomes very 
heavy and denser than normal. 
This process is also termed diffuse 
hypertrophy of the bone, but more 
frequently sclerosis ossium (con- 
densing ostitis, H. "Vblkmanri). 

Besides the hollow bones, other 
bones of the skeleton are also oc- 
casionally attacked, e. g., bones of 
the face and pelvis ; in such cases 
the bony deposits are spongy, 
puffed, nodular, so that the bone 
acquires a resemblance to skin af- 
fected with elephantiasis ; indeed, 
the diseases are very analogous 
(Leontiasis ossium, Virchow), 
The filling up of the diploe be- 
tween the outer and inner tables 
of the cranial bones with bony 
substance is such a common 
change with advancing age, that 
it can hardly be considered as 
pathological, although it really 
belongs under this head. 

The causes of sclerosis of bone 
as a primary disease are entirely 
obscure; in some cases syphilis 
may act as a cause, but the osseous 
formations occurring in this dis- 
ease rarely attain such firmness 
as in sclerosis proper. The mal- 
ady will rarely be recognized with 
certainty during life, because to 
the touch these bones present 

nothing more than a certain increase of thickness and a slight ine- 
quality of surface. 

Ostitis interna suppurativa circumscripta usually begins in a 
hollow bone as osteomyelitis. The inflammation gradually extends 
to the inner surface of the cortical substance, which is dissolved, as 
we have already stated, and finally completely consumed at some 




Sclerosed tibia and femur; the former after 
Follin, the latter from a specimen out of the 
Vienna Pathological Anatomical Collection. 



462 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

point. In such cases pus may form quite early in the centre of the 
inflammatory new formation, and subsequently be evacuated. It is 
this disease that is especially termed bone abscess. The periosteum 
does not remain unaffected ; it is thickened and new bony deposits 
form in this case also from the surface of the bone, which is not at 
first perforated but is irritated from within. The hollow bone is thus 
enlarged externally at the point where the abscess forms in it, and 
gives the impression of the bone being here pressed apart and in- 
flated. It is difficult, indeed often impossible, to distinguish such a 
bone-abscess from a circumscribed osteoplastic periostitis, hence we 
should not be in too great haste to operate. This central caries may 
be accompanied by partial necrosis of certain portions of bone on the 
inner surface of the cortical substance, forming a caries necrotica 
centralis. Lastly, we have the worst cases, where chronic internal 
and external caries are accompanied by necrosis and by suppurative 
or osteoplastic periostitis. All these develop in one and the same 
hollow bone at the same time ; abscesses appear at different points ; 
with the probe we sometimes touch rotten bone, sometimes a seques- 
trum ; in one place we enter the medullary cavity of the bone, in 
another only the surface appears diseased ; the whole bone is thick- 
ened, as is the periosteum, and a little thin pus escapes from the 
fistulous openings. The macerated preparation of such a bone has a 
peculiar appearance ; the surface is covered with very porous osteo- 
phytes; between these, here and there, we find necrosed portions 
which belong to the surface of the bone ; some openings lead into the 
medullary cavity ; if you saw through these bones longitudinally, you 
find the medullary cavity also partly filled with porous bony sub- 
stance ; the cortical layer has lost its even thickness, and it also is 
porous, so that it is only at some few points that it can be distin- 
guished from the osteophyte deposits; in the original medullary 
cavity we find occasional round holes, and in some of these necrosed 
portions of bone. These bones are in such a state that their recovery 
cannot usually be expected, and either their extirpation or amputa- 
tion of the limb is necessary. 

In the short, spongy bones the case is somewhat different; in 
them, when there is proliferating, inflammatory neoplasia, solution of 
the bone with secondary suppuration comes on quite rapidly, although 
it is not an absolutely necessary result. There are cases of ostitis of 
the short spongy bones of the wrist and ankle, and especially in the 
epiphyses of the hollow bones, where, without any decided swelling 
(which is usually caused by the resulting periostitis), the bone is en- 
tirely dissolved by interstitial granulations growing all through it, 
without any necessary accompaniment of the slightest trace of sup* 



DISLOCATION OF BONES AFTER PARTIAL DESTRUCTION. 463 

puration {ostitis interna fungosa). The result of such a solution of 
bone in these, or in other joints, is that by muscular traction the bones 
are displaced in the direction where the destruction is most advanced. 
And from this deformity we may judge approximately of the extent 
of the destruction. A short time since, I amputated a foot which was 
so distorted by such a destruction of bone, without any suppuration, 
on the inner side of the talus and calcaneus, that the inner border of 
the foot was greatly drawn up, just as in well-marked congenital club- 
foot, and the patient walked very insecurely on the outer border of 
the foot. A good-sized ulcer had also formed on the outer edge, 
which had latterly entirely prevented walking. I saw a similar case 
in the wrist-joint : A girl twenty years old had suffered for a long 
time from pain in the left wrist, without swelling of the soft parts ; 
pressure on the wrist was very painful; gradually, without any swell- 
ing or suppuration, the hand became very much abducted ; if the pa- 
tient were anaesthetized, the hand could be returned to its normal 
position, and then it was found that part of the wrist had entirely dis- 
appeared. In the larger spongy bones, as the calcaneus, and in the 
epiphyses of the larger hollow bones, a central cavity, or a bone-abscess, 
may form, and this may be accompanied by a necrosis centralis. In 
the great majority of cases, however, the ostitis is accompanied by a 
purulent periostitis ; this is particularly the case in the small bones of 
the wrist and ankle ; these are so small that, when the periosteum be- 
comes diseased, the disease readily extends to the entire bone and its 
articular surfaces, and that conversely primary disease of the bone 
quickly shows its effect on the periosteum and articular surfaces. In 
these cases also there is implication of the sheaths of the tendons 
and of the skin, which is perforated at various places by ulceration 
from within outward. In the hand the radius and ulna as well as the 
articular ends of the metacarpal bones may also be implicated, and in 
the foot the lower ends of the tibia and fibula, as well as the posterior 
ends of the metatarsal bones. The wrist and ankle joints are thus 
swollen out of shape ; in many places thin pus escapes from the 
fistulous openings, and the bones of these joints are partly dissolved 
and partly replaced by spongy granulations, or else are entirely or 
partly necrosed. It is hardly necessary to tell you that the course 
of this form of primary suppurative ostitis also, in regard to vital re- 
lations, is just as variable as that of chronic periostitis, and that here 
also you see cases of a typical atonic, and others of a fungous 
variety, while there are a variety of cases between these extremes. 

I must particularly mention one other form of chronic ostitis, viz., 
ostitis with caseous degeneration of the inflammatory neoplasia. You 
are already acquainted with this variety of chronic inflammation ; it 



464 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 



belongs generally to the atonic forms, with slight vascularization. It 
occurs chiefly in the spongy bones, and readily combines with partial 

necrosis ; in the cheesy pulp which 
fills the cavity in the bone there 
are almost always portions of dead 
bone that have not been dissolved. 
The vertebras, the epiphyses of the 
larger hollow bones, and the cal- 
caneus, are the most frequent seat 
of this ostitis interna caseosa. 
This form is only recognizable in a 
few cases during life; we grad- 
ually arrive at the diagnosis of os- 
titis interna, but can only deter- 
mine its special form in cases 
where the half-fluid caseous pulp 
is evacuated through an external 
opening. Lastly, we must not 
omit to mention that in rare cases, 
usually in the vicinity of caseous 
deposits, true miliary tubercles, 
small, at first gray, later cheesy 
nodules, come in the spongy sub- 
stance of the epiphyses in the an- 
kle-bones and vertebras and induce 
solution of the bone and partial 
necrosis. A diagnosis of this true bone tuberculosis cannot be cer- 
tainly made during life, we may onty consider it as probable where 
there is marked tuberculosis of the lungs or larynx. 

For all forms of ostitis, which induce softening of the bone-sub- 
stance, JR. VolJcmann employs the designation rarefying ostitis*. 




Foint of caseous degeneration in the spinal 
column of a man. 



From the occasional remarks that I have made concerning the 
diagnosis of chronic periostitis and ostitis, you will have already seen 
that, after they have lasted a certain time, their recognition is not 
generally difficult, but that it is not always possible to state the 
variety and extent of any given case. There are two very important 
factors for the diagnosis in those cases that cannot be examined di- 
rectly by the sound, viz., the displacement of the bones, which must 
result, in many parts of the body at least, from their partial solution, 
and formation of abscesses, which often accompanies it. 



DISLOCATION OF BONES AFTER PARTIAL DESTRUCTION. 465 

Carious destruction of the larger hollow bones rarely goes so deep 
as to cause a solution of continuity ; where this might otherwise oc- 
cur, it is often prevented by osteophytes growing on the outside while 
the destruction goes on within, so that the bone grows thicker at the 
point of disease. I have only seen one case where, from a perfectly 
atonic caries of the tibia of an old, decrepit person, the bone was at 
one point so far consumed that there were entire loss of continuity 
and spontaneous fracture; post-mortem examination showed that 
there was not a trace of osteophytes. The bone in Fig. 66 is also 
nearly eaten through. Complete destruction of the substance of the 
small hollow bones of the phalanges and metacarpi is not so rare ; the 
scrofulous caries of these bones has from time immemorial been called 
JPcedarthrocace, or spina ventosa, old names that only mean caries in 
the fingers or toes, with spindle-shaped enlargements. Should the 
bones be entirely destroyed by the fungous proliferation and partial 
necrosis of the small diaphyses, the fingers atrophy and are drawn 
back by the tendons so strongly that they represent misshaped rudi- 
ments of fingers. 

Displacement of the spongy bones is far more frequent when they 
are destroyed. I have already spoken of this as occurring in the 
wrist and ankle bones, still, it occurs far more extensively in other 
bones ; for instance, if the head of the femur and upper margin of the 
acetabulum are destroyed, the -femur is gradually drawn up in pro- 
portion to the amount of destruction, and assumes the position that it 
has in upward dislocation of the hip. Similar dislocations occur in 
the shoulder, elbow, and knee, though there they are less remarkable. 
About the most noticeable are the dislocations in the spinal column 
after carious destruction of the vertebrae ; if one or more vertebrae be 
destroyed by ostitis, the part of the spinal column lying above this 
point has no firm support, and must sink ; but, since the arches of the 
vertebrae and spinous processes are rarely diseased at the same time, 
only the anterior part of the spinal column sinks in, and an anterior 
curvature results, and a consequent posterior projection, a so-called 
Pottfs boss, thus named after the English surgeon, Percival Pott, who 
first accurately described this disease. In every anatomical collection 
you find preparations of this, unfortunately, rather common disease. 
The occurrence of such a boss is occasionally the sole, but tolerably 
certain, sign of caries of the vertebrae. 

A second important symptom of destruction of bone, or caries, is 
the suppuration which accompanies many or most cases. The pus 
collects around the diseased bone ; a cold abscess forms ; the pus does 
not always remain at the point where it forms, but sometimes sinks 
deeper, particularly when it has displaced the parts from within out- 
30 



466 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

ward, so that it reaches the loose connective tissue. The most fre- 
quent source of such sinking or congestion abscesses is the above 
disease of the vertebrae; as this most generally begins as chronic 
periostitis on the anterior side of the vertebrae, so this is the most 

Fig. 79. 




Destruction of the vertebral column by multiple periostitis and ostitis anterior. Preparation 
from the pathological anatomical collection at Basel. 



common seat of the suppuration ; the pus sinks behind the peritonaeum, 
along the psoas muscle, and usually makes its appearance below 
Poupart's ligament, and to the inner side ; it may possibly, but more 
rarely, take a different course, as backward. These congestion ab- 
scesses are of great diagnostic and of still greater prognostic value ; 



CHRONIC OSTITIS. 467 

as a rule, they are bad signs ; their treatment, of which hereafter, is 
one of the most difficult points in surgical therapeutics. In speaking 
of the sinking of pus, it is meant that, following the laws of gravity, 
the pus sinks mechanically; it will do so most readily where there 
is simply loose connective tissue present, and no opposition from 
fascia, muscles, or bone. But I must call your attention to the 
fact that this purely mechanical picture is only partly correct; for 
it is partly an ulcerative suppuration that progresses in a certain di- 
rection, which is only slightly influenced by the pressure of the pus ; 
the abscess enlarges as it does in other cases ; if the pus reaches a 
point under the skin of the thigh, perforation usually results, not from 
the mechanical pressure of the pus, but from ulceration from within 
outward, as in the opening of other abscesses; such a congestion ab- 
scess may last one and a half to two years before opening spontane- 
ously. 

We come now to the etiology of ostitis and caries interna, which 
we may treat very briefly, as the chief factors act here as in chronic 
periostitis, or in chronic inflammations generally. 

It is, on the whole, rare for injury to induce ostitis chronica ; but 
this may develop in the form of an osteomyelitis in one of the larger 
hollow bones, from severe concussion and bruising, with extravasation 
of blood in the medullary cavity ; the same thing may occur from 
contusions of the bones of the wrist or ankle. But it is more com- 
mon for such causes to induce acute disease, such as acute periostitis. 
If suppuration take place after contusion of the wrist or ankle, if the 
cartilage be destroyed and the suppuration extend to the bone, we may 
have fungous ostitis of the small spongy bones, and their complete 
destruction. Even healthy, strong persons may, from protracted 
traumatic inflammation of the joint, become so ansemic and cachectic 
that the disease will not go on to its normal termination, but becomes 
chronic. 

Most frequently scrofula and syphilis are the causes of chronic in- 
flammation of the bones ; in scrofula, while the children are fat and 
well-nourished, the fungous forms predominate. In thin, badly-nour- 
ished, scrofulous children, on the contrary, ostitis with caseous degen- 
eration and other atonic forms not unfrequently develop ; both of the 
latter lead to partial necrosis. The most frequent seats of scrofulous 
ostitis and periostitis are the vertebras, articular epiphyses, phalanges, 
and metacarpal bones ; the jaw-bones and large hollow bones are 
rarely affected. 

In syphilis, ostitis and periostitis osteoplastica are most frequent 
in the tibia and cranium ; caries sicca fungosa also occurs, some- 
times primarily in the diploe of the skull, sometimes after periostitis ; 



468 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

the sternum, palatine process, and nasal bones, are often affected ; ne- 
crosis often follows syphilitic caries. Some recent authors, such as 
JR. Vblkmann, represent syphilis of the bone as something peculiar, 
under the name of ostitis gummosa / I acknowledge that certain com- 
binations are particularly frequent, giving rise to typical pictures of 
the disease ; but, anatomically, syphilis in the bone is nothing more 
than ostitis and periostitis. In many cases, even on most careful ex- 
amination, we are unable to find any local or general cause for the 
existing caries, and I consider it better to admit this than to try with 
all our might to discover some dyscrasia. 



LECTURE XXXIV. 

Process of Cure in Caries and Congestion Abscesses. — Prognosis. — General Healtn in 
Chronic Inflammations of the Bone. — Secondary Lymphatic Enlargements. — 
Treatment of Caries and Congestion Abscesses. — Resections in the Continuity. 

Before passing to the treatment of chronic periostitis and ostitis, 
we must add a few remarks about the process of cure in caries, and 
about the prognosis. The first will vary somewhat with the activity 
of the process, as it does in ulcers of the skin. Supposing the pro- 
cess of proliferation in the new formation to cease, the interstitial 
granulation-tissue will gradually shrink together, and be transformed 
into cicatricial tissue. Considered histologically, this process consists 
of the retrogression of the gelatinous intercellular substance into firm, 
filamentary connective tissue, while the richly-developed capillary 
vessels are mostly obliterated, and the cells acquire the character of 
connective-tissue cells. If the caries was accompanied by suppura- 
tion, the latter gradually ceases, and the fistulae close. If part of the 
bone had already been destroyed by the ostitis, and there was dis- 
placement a it does not disappear, but the loss of bone is supplied by a 
retracted connective-tissue cicatrix, and the dislocated bones are united 
in their false position by such a cicatrix ; this connective tissue gener- 
ally ossifies subsequently. The cicatricial union of two dislocated bones, 
as of two vertebras, which have come into contact by the destruction of 
a vertebra previously lying between them, also ossifies, and thus 
unites the vertebras firmly ; the actual substitution of bone for any 
neoplasia to such an extent as to straighten the spine again, or en- 
tirely or partly to replace any other bone, never occurs in caries. 

Should an atonic ulcer of the bone heal, it may do so in one of 
two ways : either any portion of bone that has become necrosed must 



PROCESS OF CURE IN CARIES. 469 

be detached and thrown off, then by a rich development of vessels, a 
vigorous new formation must form from the walls of the defect, and 
when there has been a large excavation or abscess in the bone the 
entire cavity must be filled with granulations before recovery is pos- 
sible—for a perfect cure these granulations must cicatrize and ossify, 
and to a certain extent the torpid ulcer in the bone must become pro- 
liferating — or else granulations arising from the healthy bone behind 
the diseased, necrosed portion dissolve the latter ; at the same time 
the torpid process becomes proliferating, and thus leads to cicatriza- 
tion. The defects in bones, for example, in the centre of a hollow bone, 
cannot decrease by contraction, which so much curtails healing in the 
soft parts, but must be entirely filled up by new tissue. This is the 
point that so often prevents recovery in caries, for the constitutional 
conditions at the root of the torpid form of caries are often so serious 
that it is not only difficult to arrest the advance of the ulceration, but 
is just as difficult to induce active new formation in the seat of disease. 
If we actually succeed in arresting the process of ulceration, fistulae 
not unfrequently remain and continue for years, or never heal. Never- 
theless, when the disease remains stationary, the fistulae in the bone 
rarely do much harm. If you have a chance to examine such fistulae 
anatomically in macerated bones, you will find that the holes leading 
into the bone are lined by an unusually thick, sclerosed layer of bone, 
just like old fistulas of the soft parts, whose walls consist of a hard 
cicatricial substance. We have still to speak of the process of cure of 
chronic cold abscesses in certain diseases; usually, if not opened, 
these do not heal till the bone-disease is on the way to recovery. 
Then, if the cavity of the abscess be lined with vigorous granulations, 
as is rarely the case, the walls may unite immediately ; but more fre- 
quently, when such an abscess ceases to increase, it is first contracted 
by shrinkage of its inner walls, and is thus gradually closed. For 
this to occur it is requisite that the process of destruction should 
have ceased on the inner wall, and that the tissue should be suf- 
ficiently vascular. If a cold abscess do not open, but remain subcu- 
taneous, while the bone-disease recovers, most frequently a large part 
of the pus, whose cells disintegrate into fine molecules, is absorbed, 
while the inner walls of the abscess change to a cicatricial tissue, 
which, in the shape of a fibrous sac, contains the puriform fluids. Such 
pus-sacs often remain in this stage for years ; unfortunately, complete 
reabsorption, or absorption to such an extent as to leave only a cheesy 
pulp, is much rarer than might be desired, and than is usually sup- 
posed. 

In the prognosis of a case of caries, we have first to consider sepa- 
rately the fate awaitir g the diseased bone, and the state of the gen- 



470 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 



eral health induced by long suppuration of the bone and soft parts. 
Regarding the fate of the part diseased we have already said enough, 
having on the one hand described the process of destruction and its 
results on the parts around, and on the other the mode of the possible 
cure. Here I shall only add the remark that, in caries of the vertebras, 
as we may readily see, the spinal medulla may be endangered, by 
participation in the suppuration, or by being so bent, by the inclina- 
tion of the vertebrae, that its function is destroyed ; thus we may have 
paralysis of the lower extremities, of the bladder, or of the rectum, 
from caries of the spine. Practically, this is rarer than might have 
been expected a priori^ because the spinal medulla is considerably 
protected by the hard dura mater, and bears quite an amount of grad- 
ual curvature without impairment of its function. The state of the 
general health, the grade and variety of the febrile reaction, are of 
general prognostic significance. Chronic diseases of the bone rarely 
begin with fever; indeed, in many cases, especially when there is 
no local treatment, and the consecutive abscess is allowed to open 
spontaneously, the patient escapes fever altogether. But this per- 
fectly afebrile course does not continue ; if the patient has remained 
free from fever previous to the opening of the abscess, after this 
there is usually hectic fever, which is generally a remittent fever 
with steep curves, i. e., low morning and high evening temperature. 
The earlier large cold abscesses are opened the sooner the afebrile 
passes into a febrile state, and not unfrequently there is an intense, 
exhausting, continued remittent fever; the chronic ulceration then 
often becomes an acute inflammation, with great tendency to disin- 
tegration of the diseased tissue ; after the thin, flocculent, but not 
badly-smelling' pus is evacuated, there is occasionally sanious sup- 
puration, which may be only temporary. In such cases pyaemia may 
be the winding-up of the whole disease. 

It is difficult to state the cause of this change of course after open- 
ing of a cold abscess, why the chronic inflammation should so quickly 
change to an acute form. The common supposition is, that the 
entrance of air excites severe inflammation in the walls of the large 
abscess cavity, which were already disposed to disintegrate, and that 
the oxygen of the air is the especial cause of the decomposition. This 
view may be correct in many cases, but it is not the air itself or the 
oxygen that is injurious, nor is it always the organic germs contained 
in the entering air. But it is certain that sometimes puncture or 
any method of opening gives enough irritation to excite an acute, 
spreading inflammation of the badly-organized walls of the abscess. 
In many cases also infectious matters may be inoculated by the in- 
struments or dressings. [In the Medical News and Library ', July, 



PROGNOSIS OF CARIES. 471 

1878, Dr. S. W. Gross expresses his belief that the circulation and 
nutrition of the walls are disturbed by the withdrawal of the con- 
tents ; more blood is sent to the sac, its surface becomes studded 
with granulations from dilated capillaries, and pyogenesis is in- 
creased. After evacuation he recommends compression by adhesive 
plaster and bandages, and keeping the parts at rest.] The possi- 
bility of the chronic process becoming acute in this way justifies 
the prognosis that opening of the abscess increases the danger. 
We may here add that the general health is first decidedly affected 
by the suppuration ; caries fungosa, whether running its course 
without suppuration or with only a slight amount, is consequently 
less dangerous to life than caries atonica, with great tendency to 
suppuration and decomposition. This prognostic point is also based 
on good grounds, for, as we have previously stated, proliferating 
inflammatory new formations more frequently occur under compara- 
tively favorable constitutional conditions. If the fungous prolifera- 
tions break down quickly, if the suppuration becomes more profuse 
and thinner, it is a bad sign, a sign that the general health has also 
become impaired. 

The strength is used up partly by the production of pus, partly by 
the fever, and is only partly replaced because reabsorption does not 
go on properly from the stomach, digestion is not good ; this reacts 
again on the local disease, and thus the general and iocal state are 
most intimately connected. The smaller the carious spot, the less 
dangerous it is for the general health ; still there are certain localities 
where it is more dangerous than elsewhere ; thus suppuration of the 
vertebrae, with large congestion abscesses, is very dangerous, while 
caries of the phalanges, even if several be attacked, has little effect 
on the general health ; there is great difference in the danger to life 
according to the joint and diaphyses attacked ; caries of the hip, knee, 
or ankle, is far more dangerous than in the shoulder, elbow, or wrist. 
Of this we shall speak more particularly when treating of diseases of 
the joints. 

The age is also of great prognostic importance in caries — the 
younger the patient the better hope of recovery ; the older he is, the 
less hope : in caries coming after the fiftieth year, whether a sequent 
of periostitis or primarily as ostitis, the prognosis as to recovery is 
very doubtful, insignificant as the local disease may be at first ; I do 
not remember ever to have seen caries in old persons so frequently as 
at Zurich. Lastly, the prognosis depends greatly on the constitutional 
disease to which the caries is due. Relatively, syphilitic caries is the 
most favorable, "because we can treat syphilis the most successfully. 
In well-nourished children scrofulous caries also is rarely dangerous to 



472 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

life, as the scrofula disappears spontaneously, or after the use of proper 
remedies. But caries in atrophic scrofulous children is dangerous, be- 
cause such children easily die of exhaustion. The prognosis in caries 
is most unfavorable where there is already pronounced tuberculosis ; it 
very rarely recovers ; the pulmonary disease generally advances rapidly 
and acute miliary tuberculosis develops in the serous membranes, and 
sooner or later terminates life. 

The patient, dying slowly from chronic suppuration, gradually 
grows more and more emaciated, pale, and very anaemic, at last 
oedema of the lower extremities comes on ; he eats less, and finally, 
after years of suffering, he dies of marasmus, often very slowly ; some- 
times he sinks to rest quietly ; sometimes struggles for days with 
death. Formerly it was generally supposed that death in these cases 
was solely due to gradual exhaustion ; but more careful examinations 
have shown that the exhaustion and impoverishment of the* blood 
often have very palpable causes. For in these cases we often find the 
liver, spleen, and kidneys, in a state of fatty or amyloid degeneration 
(Hyalinose, 0. Weber), a variety of degeneration which consists in the 
deposit in the substance of the organ, from the smaller arteries, of a 
peculiar material characterized by its lardaceous consistence, and by 
its reaction ; on addition of iodine and sulphuric acid, it colors partly 
deep-reddish brown, partly dirty-brown violet, with a play of colors 
into green and pale red. Concerning the nature of this material there 
are various views, which you will find more detailed in the patho- 
logical anatomies. I shall only tell you here that the above reaction 
with iodine and sulphuric acid is similar to that of cholesterine, and 
that consequently Heinrich Meckel von Hemsbach believed that the 
fatty substance owed its reaction to the large amount of choles- 
terine it contained. Others thought that this material was allied to 
amylum, and hence Virchow, who held this view, called it amyloid. 
Kuhne subsequently showed that both of these views were untenable. 
The so-called amyloid is a peculiar substance, closely allied to albu- 
men ; it differs from albumen particularly by its insolubility in acids 
containing pepsin. From the mode of its occurrence this material is 
very interesting and noteworthy ; it and fibrine are the only organic 
bodies we know that pass in fluid form through the vessels, and out- 
side of these coagulate firmly in the living body, without the vital 
power of cells appearing necessary. 

The saturation of the liver, spleen, and kidneys, as well as of the 
walls of the intestinal arteries and of the lymphatic glands, with fat, 
must naturally have great influence on the formation of the blood, and 
finally prevent it entirely ; thus, in most of these cases death is caused 
by disorganization of the blood. Extensive chronic suppurations 



TREATMENT OF CHRONIC PERIOSTITIS. 473 

greatly predispose to fatty degenerations; hence, in patients with 
extensive caries we should carefully attend to this point, though fre- 
quently we cannot avert it. Besides tuberculosis and amyloid degen- 
eration, which unfortunately not unfrequently combine, these poor 
patients are occasionally also endangered by the common forms of 
acute and chronic diffuse nephritis, or morbus Brightii. 

I will also mention that, in chronic inflammation of the periosteum 
and bone, the proximal lymphatic glands often participate in the dis- 
ease. As in acute inflammations the lymphatic glands are often 
infiltrated and excited to acute inflammation by material coming to 
them from the point of disease, so in chronic inflammations the same 
thing occurs and from the same cause. The lymphatic glands swell 
slowly, painlessly, but often enormously in the course of months and 
years ; the tissue of their frame-work thickens, some lymphatic ves- 
sels are obliterated, while others increase in size ; rarely it goes be- 
yond this hyperplastic swelling ; occasionally there are small abscesses 
and points of caseous degeneration. 



Now, after having examined chronic periostitis and ostitis from all 
sides, it is time to think of the treatment. In so doing, after having 
spoken of these diseases in their most varied extent and combination, 
we must again begin with simple chronic periostitis. The treatment 
should be at once general and local ; in all cases where dyscrasial 
causes are evident, they should be chiefly treated, and on this point I 
refer you to what was said in the general consideration of these dys- 
crasice in the chapter on chronic inflammation. Therefore in this place 
we shall chiefly consider local remedies. Rest of the diseased part is 
the first and most general rule in the treatment of chronic inflamma- 
tion of the bone; for movement, accidental blows, falls, etc., may 
change what would have been a mild, not injurious course, to an acute 
and dangerous one ; hence, in most cases of disease of the bones of 
the lower extremities lying quiet is of the first necessity, in the upper 
extremities carrying the arm in a sling. This rest is particularly im- 
portant in diseases of the bone near the joints ; under such circum- 
stances rest is often spontaneously resorted to because motion is pain- 
ful. Some forms of fistulous caries become so quiet and painless, 
when suppuration externally begins, that motion has no effect on the 
diseased bone, and in such cases moderate motion may be allowed. 

Elevation of the diseased part is a good adjuvant to the treatment, 
for it avoids venous congestion. This mechanical aid to the escape 
of the blood must not be undervalued. 34 

When the first symptoms of chronic periostitis and ostitis begin, 



474 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

treatment should aim at inducing resolution. For this purpose, power- 
ful antiphlogistic remedies are of little use. The application of 
leeches or cups, the internal administration of purgatives, the appli- 
cation of bladders of ice, seem to me only beneficial in acute exacer- 
bations of chronic inflammation ; their action is always very tempo- 
rary, and the employment of local bloodletting and purgatives may 
even prove injurious if often repeated. The repeated application of 
leeches and cups proves locally irritant, and may finally make the pa- 
tient anaemic, and a continuance of laxatives exhausts his strength ; 
hence we should employ these remedies sparingly, reserving them for 
the acute exacerbations. Recently Esmarch has very urgently recom- 
mended the continued application of bladders of ice in chronic in- 
flammation. In cases accompanied by great pain, I have seen very 
good effect from this treatment ; in other cases I see no true indica- 
tion for their use. 

Most frequently, at the very commencement of chronic inflamma- 
tion of the bone, the resorbent and milder derivative remedies are 
proper : officinal tincture of iodine, ointment of iodide of potash, 
mercurial ointment weakened by the addition of lard, mercurial plas- 
ter, ointments made with concentrated solution of nitrate of silver, 
hydropathic dressings and mild compression-bandages. With these 
remedies, and proper constitutional treatment, we make our first at- 
tack on the diseases in question, if they are just commencing, and 
occasionally we succeed in arresting them at an early stage. In the 
early stages of serous and moderately-plastic infiltration and slight 
vascular ectasia, the retrogressive changes either occur without leav- 
ing a trace of morbid change, or perhaps leave a moderate formation 
of osteophytes. In this stage, the treatment of syphilitic diseases of 
the bone by active antisyphilitic remedies is the most successful. 

If the process progresses, and the caries runs its course without 
suppuration, we may continue with the above remedies, and in suit- 
able cases, in otherwise vigorous persons, may combine with the 
above, derivatives to the skin, such as fontanelles, the hot-iron, etc. 
If the signs of suppuration begin, and abscesses form, you may con- 
tinue the absorbent remedies for a time, in the hope of even yet in- 
ducing reabsorption ; it is true, this will not succeed in most cases, 
but the question will soon arise : Shall we open the abscess, or wait 
for it to open ? On this point I give you the following general rule : 
If the abscess comes from a bone on which an operation is impossible 
or undesirable (as the vertebrae, sacrum, pelvis, ribs, knee-joint, etc.), 
do not meddle with it, but be thankful for every day that it remains 
closed, and wait quietly till it opens, for thus there will be relatively 
the least danger. When I have departed from this principle, I have 



TREATMENT OF CHRONIC PERIOSTITIS. 475 

always regretted it. I saw, with great pleasure, that Piriogoff said 
almost exactly the same thing. Experience has sufficiently shown 
that none of our operations, aiming at imitating the slow spontaneous 
opening of these abscesses, prove as little irritating as the slow per- 
foration of the skin from within by ulceration. Various methods have 
been proposed for opening large cold abscesses, corresponding to the 
theories in regard to them. For a time it was thought that the pus 
must escape slowly, in order to prevent inflammation of the abscess- 
walls. To accomplish this, setons were introduced, and the pus 
allowed to trickle from the points of opening. Then it was claimed 
that, besides this slow escape of matter, the skin should be perforated 
slowly. For this purpose, a caustic was applied to the thinnest spot 
of the abscess, and a slough made, which gradually became detached, 
whereupon the pus slowly escaped. Subsequently it was supposed 
that we should carefully avoid the entrance of air, as this was the 
dangerous point ; so a trocar was introduced, a portion of the pus was 
evacuated and the opening accurately closed, or the so-called subcu- 
taneous puncture, according to Abernethy, was made, i. e., the skin 
over the abscess was lifted up, and a narrow-bladed knife was passed 
under it into the abscess, a large part of the pus was evacuated ; then 
the knife was quickly withdrawn, and the skin allowed to go back 
into its original position, so that the puncture in the skin did not 
communicate directly with that in the abscess-sac, but the latter was 
covered by the skin ; the cutaneous opening was carefully closed. 
Subsequently great importance was attached to placing the walls of 
the abscess in such a condition that the formation of pus should cease ; 
it was thought that this could be done by injecting solutions of iodine 
after the pus was evacuated ; this method was especially popular in 
France. Recently a French surgeon (Chassaignac) has returned 
with great enthusiasm to the old setons ; but, instead of these, he 
chose fine tubes of caoutchouc with perforated walls, so that the escape 
of the pus was greatly facilitated (Drainage, page 176). Lister, an 
English surgeon, particularly urges that in opening these abscesses 
the instruments and dressings should be previously disinfected with 
carbolic acid, and also that the entrance of air should be carefully 
avoided ; his proceeding, like all previous ones, has enthusiastic advo- 
cates. It is not easy to decide on the value of all these methods ; 
but, when such a number of remedies and methods are recommended, 
you may almost always decide that the disease in question is very 
difficult to cure, and that none of the remedies are suited for all cases. 
Let us briefly criticise the above plans of treatment. A single evacu- 
ation of the pus, do it as we may (we regard free openings of con- 
gestive abscesses as universally abandoned), has at first a tolerable 



476 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

result, if done slowly and carefully, whether with the trocar or sub- 
cutaneously with the knife, with or without Lister's carbolic-acid 
treatment. If the opening is nicely closed and heals up, there is usu- 
ally no fever, but the abscess fills again very quickly ; an abscess that 
probably took ten months to form, may fill again in ten days. This 
is also punctured ; the opening again closes ; the patient grows fever- 
ish ; the pus again collects rapidly. A third, and perhaps a fourth or 
fifth, puncture is made, always in a new spot ; the patient grows more 
feverish, the abscess is hotter and more painful ; the patient looks 
languid and suffering. Now the points of puncture cease to heal, the 
previous ones open again, there is a continual escape of matter, and 
occasionally, in spite of all our care, air enters, especially when the 
walls of the abscess are rigid and do not collapse. Now there is a 
fistula, the fever is continued, and the subsequent course is most un- 
favorable, as we described it above. So far as my experience goes, 
the course is not much changed if the puncture be followed by injec- 
tion of iodine. There is not much difference if you make the opening 
with a seton, with drainage-tubes, or by cauterization. I have seen 
nothing from any of these methods that in the least approximated the 
claims of their proposers. 

It is true this unfortunate course may be run if you do nothing to 
the abscess but leave it to itself and await its opening ; but then all 
progresses more mildly and slowly, and fever comes on later. Recov- 
eries take place under all these modes of treatment, but I think there 
are more recoveries, and certainly fewer deaths from pyaemia, under 
the expectant treatment. I am satisfied that where recovery has fol- 
lowed injections of iodine, drainage, etc., it would also have occurred 
had the course of the disease not been interrupted ; we cannot accept 
the assertion that a case would have run its course thus and so, if this 
and that had not been done. Summing up my own experiences, I 
can assure you that, of very many cases of large congestive abscesses 
along the spinal column, artificially opened, I know very few that ran 
a favorable course ; the others were only hastened to their end. Hence 
I again repeat the previous assertion, that these abscesses, especially 
congestive abscesses from caries of the vertebrae, are a noli me tangere. 
In such cases it is indeed frequently very difficult to wait ; in private 
practice, especially, the patients become impatient ; the surgeon is urged 
to do something, it is cast up to him that he does not try any thing ; 
the public firmly believes that, if the pus was only out, recovery must 
follow. The surgeon also at length becomes weary; it is trying 
to look on from week to week as the abscess increases; all local 
and constitutional remedies are exhausted, and finally the surgeon 
departs from his principles and makes an opening ; at first all goes 



TREATMENT OF BONE ABSCESSES. 477 

well, but this does not continue ; you already know the subsequent 
course. 

The case is somewhat different when we have to deal with small 
abscesses originating in disease of bones of the extremities ; in suppu- 
rations connected with the larger joints, we also willingly postpone 
opening ; we shall speak of this hereafter, under diseases of the joints. 
In cold abscesses from the diaphyses delay is not of much avail ; here 
I rather consider an early opening as proper, except in syphilitic 
gummata ; in these cases there may be reabsorption, even after there is 
evident fluctuation, and in markedly tuberculous or debilitated persons, 
in them no operative interference is indicated, and opening the abscess 
would only induce profuse suppuration, without doing any good. In 
the other cases I am in favor of opening the abscess freely, to obtain 
a clear view of the variety and extent of the disease ; under these 
circumstances the reaction is insignificant, frequently there is no 
fever, often there is moderate fever for a short time. Let us suppose 
a chronic periostitis with caries superficialis of the diaphysis of a 
hollow bone ; an abscess has formed and been opened ; the wound is 
at first dressed with charpie, and we then wait to see what appear- 
ance the surface of the ulcer will assume. The local treatment should 
be modified according as the ulcer is proliferating or accompanied by 
breaking down of tissue, and I should only be repeating, were I to 
refer again to the proper remedies. The treatment may be aided by 
local baths, which we may render slightly irritant by the addition of 
potash or tincture of iodine. Wet compresses, cataplasms, charpie- 
wads wet with various fluids, serve as dressings. The subsequent 
course will show more and more to what extent the bone-disease de- 
pends on the general health. If the patient be a weakly, tuberculous 
individual, all local remedies are in vain ; if the general health be 
good, you may even resort to energetic local treatment. If the ulcer 
does not improve under milder remedies, you may apply the hot iron ; 
should this be followed by formation of strong, healthy granulations, 
it is a favorable sign, even if there be necrosis of the carious portion of 
bone. In other cases we abandon all idea of inducing healing, and cut 
out the entire affected part. For this purpose there are various forms of 
cutting forceps and saws ; I prefer detaching the diseased bone with 
scrapers, gouges, and hammer, to all other methods. If the ulcer of 
the bone has been cleanly cut out, and the general health be tolerably 
good, it is to be hoped that the wound of the bone made in the opera- 
tion will heal normally by healthy granulation and suppuration, as 
other wounds of bone do. Should the caries affect a small bone, it 
may be proper simply to extirpate it, to arrest the process at once. 
If the case be one of ostitis interna, caries centralis of a hollow bone. 



478 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

or of a large, spongy bone, such as the calcaneus ; if severe pain and 
other previously-mentioned symptoms of bone-abscess gradually ap- 
pear, it may become proper to chisel out the bone, or open the cavity 
of the bone and let out the pus ; but I only advise this operation when 
you are sure of your diagnosis, for it is no slight injury to a patient 
to have a healthy medullary cavity opened. Yery acute osteomyelitis, 
with its often dangerous results, may arise from untimely interference, 
while a similar operation on a diseased bone is not usually very seri- 
ous. In other cases you will await the spontaneous opening of the 
abscess through the bone ; then you may use a probe, and judge accu- 
rately of the state of affairs. The obstacles to the healing of such 
excavations in the bone have been previously mentioned ; should the 
process remain stationary for a long time, it may be best to enlarge 
the opening in the bone, expose the abscess, and remove its walls ; 
this will be the more necessary if there are any small necrosed por- 
tions of bone in the abscess-cavity which prevent its healing ; that is, 
if the case be one of caries necrotica. But all these manipulations 
are only indicated if the general health be good; if there be ad- 
vanced tuberculosis or marasmus, and the disease will necessarily 
prove fatal, no surgeon would wish to do an operation which can only 
prove successful when the local changes in the new wound of the 
bone go on normally. These operations, part of which, at least, may 
be classed among the partial resections in the continuity, have lost 
their cruel and terrible appearance since the introduction of chloro- 
form, by whose aid the patients escape feeling the chisel, hammer, 
and saw. 

In those cases where the caries is so extensive as to affect the 
whole thickness of a long bone, we might think of sawing out the en- 
tire diseased part. This case is very rare, and such operations are of 
extremely doubtful benefit. We might, it is true, saw out a piece from 
the middle of the fibula, radius, or ulna, from the metacarpal or meta- 
tarsal bones, without greatly impairing the function of the extremity ; 
but, should we do the same for the humerus, femur, or tibia, and re- 
covery take place, the function of the extremity would, at most, only 
be partially restored by aid of an apparatus ; in the lower extremity 
an artificial leg would be of more use than a leg that had lost a con- 
siderable portion from the continuity of the bone. It has been 
thought that the periosteum, detached from the bone before it is 
sawed, and left in the wound, would form new bone ; but after opera- 
tions for caries this regeneration of bone is very scanty, so that we 
cannot count much on it. Moreover, caries is the rarest indication for 
these total resections in the continuity. 

Lastly, in regard to those cases which are on the whole rare, where 



TREATMENT OF BONE ABSCESSES. 479 

a hollow bone is diseased throughout with periostitis, external and 
internal caries, partial internal and external necrosis, there can only 
be a question of extirpation of the entire bone, or amputation of the 
affected limb, Cases of extirpation of the entire ulna or radius oc- 
casionally turn out well ; extirpations of the first metacarpal bone are 
often successful. I also know of a case where the whole humerus 
was removed, leaving behind the thickened periosteum ; but the pa- 
tient died a few months after the operation from some internal dis- 
ease, morbus Brightii, if I mistake not, so that no decision could be 
made about the usefulness of the extremity ; in spite of the absence 
of the humerus, the hand might have been of service, which of itself 
would have been a great gain to the patient. Caries of the short, 
spongy bones, and of the articular epiphyses, is so intimately con- 
nected with diseases of the joints that we shall discuss it hereafter. 

The state of general marasmus that finally occurs from diseases 
of the bone, with extensive suppuration, is to be treated on general 
principles. We should try to prevent its occurrence, or at least ward 
it off to the utmost. It is the physician's duty to preserve life as 
long as possible. It is also his duty, even in a patient almost cer- 
tainly dying, to give him every thing that can keep up his strength. 
Nourishing, tonic, strengthening diet is to be given from the time 
the first symptoms of emaciation show the failure of nutrition ; later 
it is of no use. In children and young persons the inexperienced 
physician may readily be deceived as to the strength, and you will 
hereafter see that patients in a very bad state, emaciated to a skele- 
ton, and excessively anaemic, pick up wonderfully and unexpectedly 
on amputation of the diseased limb, which seemed to be consuming 
their life ; of course benefit could rarely result from resection under 
such circumstances. How far it is safe to carry the principle of pre- 
serving the limb by sawing out the diseased portion of bone can 
only be judged of in individual cases, and then only approximately. 



LECTURE XXXV. 

Necrosis.— Etiology.— Anatomical Conditions in Total and Partial Necrosis. — Symp- 
toms and Diagnosis. — Treatment. — Sequestrotomy. 

Gentlemen : We have already frequently spoken of " necrosis," 
and you know that by this term we mean gangrene of the bone, 
death of a bone, or part of a bone. I have also told you that the dead 
portion of bone is called a sequestrum. You also know that necrosis 



480 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

may result either from an acute process, or accompany the process of 
ulceration as " caries necrotica." 

As in death of any part, cessation of circulation is also the im- 
mediate cause of necrosis, while cessation of nervous activity does 
not induce it, although a disturbance of nutrition, an atrophy of the 
bone, is occasionally seen in paralyzed parts. Necrosis may be due 
to various causes ; we shall briefly group them together : 

1. Traumatic influences. Among these are severe concussions and 
injury of the bones, even without external wounds. The course is as 
follows : As a result of the above injuries there are extravasations 
in the medulla of the bone, also into the spongy bones, perhaps also 
in the compact bony substance, and occasionally under the periosteum. 
If these ruptures of the vessels be so extensive that their results 
cannot be removed by collateral circulation, which is of difficult es- 
tablishment in bone, part of the bone will no longer contain any 
blood ; this will die, and, according to circumstances, we may have 
central, superficial, or total necrosis (the latter occurs most readily in 
the small bones). The portion of dead bone remains in the organism 
as a foreign body, but still continues in continuity with the healthy 
bone ; the solution of the sequestrum, by liquefaction of the bone- 
substance in the border of the living tissue, has been already ex- 
plained (page 220). Another mode of injury is exposure of the sur- 
face of the bone, or sawing through a bone, by which the sawed sur- 
face becomes the surface of the bone ; in complicated fractures a 
piece of bone may be so denuded of soft parts, and thus robbed of 
its circulation, that it becomes necrosed. We have also explained 
why the exposed bone or sawed surface does not always become ne- 
crosed, but that the bone may, like the soft parts, immediately pro- 
duce granulations. Nevertheless, after the above injuries, superficial 
or partial necrosis is common enough, either because extensive clots 
form in the ends of the injured vessels of the bone, or because the 
vessels are compressed and suppurate on account of the acute suppu- 
ration in the Haversian canals. 

2. Acute periostitis, ostitis, and osteomyelitis, are very frequent 
causes of occasionally extensive and especially of total necrosis of 
the hollow bones. In suppuration of the periosteum the supply of 
blood to the bone, by vessels passing through the periosteum, is cut 
off, and the suppuration is propagated through the Haversian canals 
to the medullary cavity ; if the latter also suppurates, necrosis is in- 
evitable, and will extend as far as the inflammation did. The same 
results will occur in primary acute ostitis and osteomyelitis with sec- 
ondary periostitis. 

3. Chronic ostitis and periostitis may combine with necrosis, for, 



ANATOMY OF NECROSIS. 481 

just as in the acute processes, suppuration, change of the inflamma- 
tory new formation to detritus or caseous matter, extends into the 
bone, and so impairs its circulation that part of the bone is no longer 
nourished and must necrose ; atonic forms of caries induce necrosis 
more readily than the fungous forms, as has already been stated. 

The necrosis that is supposed to occur after thrombosis or embo- 
lism of the chief trunk of the nutrient artery of a bone appears to 
be of more theoretical than practical importance. This variety of ne- 
crosis has hardly been proved by dissections on man ; it is, moreover, 
very improbable, because the arterial supply, in full-grown bones, 
comes from so many sources that stopping one of the many afferent 
branches does not suffice to completely arrest the circulation in any 
considerable portion of bone. Although the collateral circulation in 
bone cannot, from mechanical causes, be greatly facilitated by dilata- 
tion of the vessels, and hence in capillary stasis there is always danger 
of partial necrosis, as already stated, still the connection, arrange- 
ment, and regular distribution of the capillaries, even in the firm cor- 
tical substance, are such that when the afflux is interrupted from one 
source it may easily come from another. In bone there are no defined 
capillary net-works and capillary groups as in the skin', but all the cap- 
illaries are intimately connected in all directions, as in the muscles. 

The experiment of inserting a peg into the foramen nutritium in 
the upper part of the tibia of rabbits has been tried, and it has been 
followed by necrosis around the peg. I have made this experiment 
and obtained the same result by inserting the peg at any other part 
of the bone, and hence I believe that this experimentally-induced ne- 
crosis depends only on the variety of the injury to the bone. 

It will be proper now to study more accurately the anatomical 
course of necrosis, especially of that coming after acute periostitis 
and osteomyelitis. I have already told you, on various occasions, 
when treating of the healing of fractures and of chronic ostitis and 
periostitis, that the vicinity of such collections of pus is almost al- 
ways affected in such a way that osteophytes form on and in the 
bone ; their development is greatly influenced by the periosteum, and 
also by the surrounding parts (where they form after fractures). 
While solid healing is due to this new formation of bone after frac- 
tures, in chronic ostitis and periostitis it is more an accidental prod- 
uct of irritation, which subsequently has no further significance. 
The same thing is true in superficial necrosis. When, from new de- 
position of osteophytes around the sequestrum, the bone becomes 
more dense around the point of disease, whether this be exfoliation 
of one of the cranial bones, or a sequestrum from a sawed surface, 
it has no further practical importance. It is different in complicated 
31 



482 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

fractures : when the broken ends or nearly loose fragments of bone 
become necrosed, the formation of new bone in the vicinity may not 
only induce future firmness in the bone, but the sequestrum may be 
entirely enclosed by the new bone, and it may be necessary to remove 
it by operation. But this formation of new bone is most important 
in total necrosis of entire diaphyses; it is intended to replace the 
bone which dies. This very important process, which is so wonder- 
fully accomplished by Nature, we must now study more carefully. 
Let us suppose an acute total periostitis and osteomyelitis with ne- 
crosis of the diaphysis of the tibia. The entire periosteum and me- 
dulla have suppurated ; within the bone the pus falls to detritus, or 
actually putrefies ; the pus from the periosteum has perforated the 
skin at various points, the circulation in the diaphysis has ceased ; the 
entire diaphysis is a sequestrum. A longitudinal section gives the 
following appearance (Fig. 80) : 

Pig. 80. 




Diagram of total neerosie of the diaphysis of a hollow hone. 



a, the sequestered bone ; b b, its upper and lower extremities ; c c, 
pus surrounding the sequestrum ; d d, where it has perforated exter- 
nally. The darkest layer, e e, is the wall of a large abscess-cavity, 
which consists of tissue (connective or tendinous tissue, or even of 
muscle), infiltrated with plastic matter, and on its inner surface, which 
lies next the sequestrum, like any abscess-cavity, it has a granulation- 
layer, which constantly produces new pus. I will mention at once 
that this view, as in acute periostitis, differs from that of other sur- 
geons and anatomists, because they suppose the tendinous portion 
of the periosteum is lifted, like a vesicle, from the bone by the pus ; 
this is incorrect, because the tendinous portion of the periosteum is 
not sufficiently elastic to be quickly elevated like an epidermis vesicle, 
and because this elevation would fail to occur at those points where 
there is no periosteum, i. e., where tendons are attached to the bone ; 
but the latter is not the case. The inflammation and suppuration 



DETACHMENT OF THE SEQUESTRUM. 483 

begin partly in the surface of the bone, partly in the softer parts of 
the periosteum, in its outer layers ; the tendinous portion participates 
but little ; indeed, it is mostly destroyed. In proof of this I have very 
decided anatomical evidences. The anatomists and surgeons who 
believe in the elevation of the periosteum consider the shaded layer, 
e e, as infiltrated, thickened periosteum ; this is only conditionally 
true : it may happen that part of the periosteum does not suppurate 
and enters into the composition of this layer ; however, other adjacent 
parts may also be so indurated by plastic infiltration as to form a firm 
abscess membrane, as is often seen in abscesses of the soft parts. 
Whoever maintains the exclusive power of the periosteum to produce 
bone will, on theoretical grounds, regard this layer, e e (where bone 
is subsequently formed), as thickened periosteum. But, in the forma- 
tion of callus, after fractures, we have already seen that bone in con- 
siderable quantity may under certain circumstances be produced in 
other soft parts lying near the bone, and hence we are not obliged to 
demand periosteum in this thickened layer of the abscess. 

But we are going on too rapidly. Let us return to our example. 
The pus-cavity around the sequestrum cannot close till the latter is 
out of it; but this remains attached at both ends. You already know 
how the detachment is effected : at b b, in the edges of the living bone, 
there is an interstitial proliferation of granulations, by which a slight 
amount of bone is consumed, so that at last the osseous substance is 
entirely replaced by soft granulations at these ends ; this completes the 
detachment of the sequestrum (see page 220) ; the granulations form- 
ing here break down somewhat, soften to pus, and then the seques- 
trum lies loose in a pus-cavity, which is filled with proliferating granu- 
lations. In the thick hollow bones this detachment of the sequestrum 
requires a long time, usually several months, sometimes over a year ; 
up to this time the pus has escaped from the places where it had per- 
forated the skin ; if, during this time, you introduce a probe through 
the openings, you may usually feel the smooth surface of the diaphysis. 
But, during this process of detachment of the sequestrum, something 
else is generally going on in the immediate vicinity, to which we shall 
now turn our attention. In the thickened layer of the pus-cavity, e e, 
new osseous tissue has formed regularly around the sequestrum longi- 
tudinally ; this ossification has also continued to the part where the 
thickened layer again joins the periosteum of the epiphysis and the 
capsule of the joint, so that the bone-capsule is intimately connected 
with the epiphysis above and below. The longer the sequestrum 
remains in the cavity, the more the bony envelope increases in thick- 
ness ; in time it becomes very thick ; in the course of years, if the 
sequestrum does not come out, it may be over half an inch thick ; at 



484 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

first, it consists of porous bone, but subsequently is more compact and 
stronger. A regular cast has been formed around the sequestrum, 
just like we should make of plaster of Paris if we wish to mould an 
object ; this cast, however, has several openings, especially where the 
pus escapes ; their closure is prevented by the constant flow of pus. 
The above picture (Fig. 80) has now changed to the following 
(Fig. 81) : 

Fig. 81. 




Diagram of total necrosis of the diaphysis of a hollow bone, with a detached sequestrum and 

new bony receptacle. 

The sequestrum a is detached and bathed in pus, which is secreted 
from the granulations above mentioned; d d, the fistulas leading into 
the pus-cavity (they have received the name cloaca) ; e e is the bony 
envelope derived from the ossification of the thickened abscess-wall, 
the so-called bony receptacle. This thickening now progresses regu- 
larly, if the irritation caused by the sequestrum continues. Let us 
now suppose that the sequestrum escapes from its case (as happens 
occasionally — of this later), then, although all the bone of the diaphy- 

Fia. 82. 




Fig. 81, after removal of the sequestrum. 



sis is lost, there is no disturbance of function, for the newly-formed 
bony envelope supplies the place of the bone that has been lost. 

Now, what happens ? Will the cavity in which the sequestrum 



DETACHMENT OF THE SEQUESTRUM. 



485 



lay continue to suppurate ? No ; if every thing goes on normally, 
this cavity, like other cavities due to central caries, fills with granula- 
tions ; these granulations ossify, and the bone is completely restored, 
at least as regards its form ; observation has not yet determined 
whether the medullary cavity again forms in such cases as it does 
after the healing of fractures, but from analogy this is not improbable. 
After removal of the sequestrum, the healing of these cavities often 
requires months and years, sometimes it is never complete, especially 



Fig. S3. 



Fig. 84. 





<', total necrosis of the diaphysis of the femur, with 
extensive bony case replacing the dead portion of 
bone ; several good-sized openings lead through 
this bony case to the sequestrum within. 

&. longitudinal section of the same preparation. 



a, tibia of a young man after total 
necrosis of the diaphysis ; about 
two years previously I had re- 
moved the sequestrum, b\ the 
cavity has almost filled with os- 
teophytes. The patient died from 
a carbuncle. 



486 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

if the individual affected be constitutionally diseased, or becomes so 
from the continued suppuration accompanying the process. In these 
long-continued suppurations from bone, albuminuria not unfrequently 
develops, although of rather mild form. I do not know whether this 
may in time spontaneously disappear after the cavity in the bone has 
healed ; it would be interesting and of prognostic importance to collect 
observations on this point. After removal of the sequestrum, the thick- 
ening of the osseous envelope ceases, and the process of ossification 
establishes itself in the cavity filled with granulations. What I have 
just demonstrated to you in diagrams, you here see in these beautiful 
preparations from the anatomical and surgical collection of Zurich. 

You now know the ordinary normal course of a necrosis. I must 
next introduce you to some deviations from this normal course. You 
will remember that, when speaking of acute periostitis, I told you that 
occasionally the epiphyseal cartilages also ossified (where they still 
existed, that is, in young persons). When this takes place simulta- 
neously in the upper and lower ends (a very rare case), of course the 
sequestrum will be detached, and detached very early, so early that 
no bone can have yet formed in the pus-cavity, or, if it has, it must 
still be very weak. If the bone be now extracted, there is nothing 
yet formed to replace it, nor does any thing form, because the irritation 
which gives rise to the production of bone is absent, this cause of irri- 
tation being the sequestrum, as long as it remains as a foreign body 
in the bone ; hence, under these circumstances, if the sequestrum be 
extracted early, the extremity becomes boneless and unserviceable. 
When the epiphysis cartilage suppurates at one end, e. g., the lower 
end, the sequestrum remains firmly attached above, and the break- 
ing down of the bone must go on slowly as in other cases ; it may, 
however, happen, as I saw in one case in the thigh,that the lower end, 



Fig. 




Necrosis of the lower half of the diaphysis of the femur, with detachment of the epiphyseal 
cartilage, and perforation of the skin. 



DETACHMENT OF THE SEQUESTRUM. 



487 



loose in the epiphysis cartilage, presses strongly against the skin from 
within and gradually perforates it, so that it appears externally ; the 
lower epiphysis of the femur was at the same time drawn up by the 
muscles, so that the appearance was as follows (see Fig. 85). 

The sequestrum, subsequently removed, had the following form 
(Fig. 86) : 

Flo. 86. 




The body extracted from Fig. 85. 

The formation of bone was strong enough to carry the body ; sub- 
sequently, under chloroform, the knee was straightened, and perfect 
recovery resulted. I saw a perfectly similar case affecting the lower 
end of the humerus. In both cases, as is usual in necrosis near the 
joints, the joint had suffered severely, and became quite stiff. Still, 
even without early detachment of the sequestrum from softening of 
the epiphyseal cartilages, under circumstances which we do not accu- 
rately know, the formation of bone may be very feeble, so that, after 
the detachment, the new bone is not firm at some point, but is quite 
flexible, whereby we have a pseudarthrosis of the new bone ; I have 
seen two cases of this kind : one of these I cured completely by occa- 
sionally driving ivory plugs into the weak part of the newly-formed 
bone, thus constantly stimulating the bone to new production ; the 
object was attained in the course of eight months, and the patient, 
then twelve years old, now walks like a healthy person. 




Diagram of partial necrosis of a hollow hone. 



488 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

Partial necrosis of the diaphysis is more frequent than the above 
complete necrosis ; this may either affect the entire thickness, or only 
half the circumference, according to the extent of the osteomyelitis and 
periostitis. You may readily apply what has been said to these par- 
tial necroses. Here is an example : suppose a periostitis of part of 
the diaphysis of one femur and subsequent necrosis ; the circumstances 
may assume the following shape (see Figs. 87 and 88) : a, seques- 
trum ; b b, its borders ; c c, the pus-cavity ; d, the perforation out- 
ward ; e e, the thickened ossifying wall of the pus-cavity. 

A few months later (Fig. 89) ; a, detached sequestrum, which is to 

Fig. 88. 




Diagram of Fig. 87 in the later stages, with formation of new bone. 

be removed ; e e, newly-formed bone-tissue as substitute for the piece 
of bone that is being lost ; of course, the newly-formed bone covers 
the sequestrum anteriorly, but, as in Figs. 80, 81, and 82, must be left 
out to expose to view the sequestrum. 



Fig. 




Fig. 88, after removal of the sequestrum. 



The changes that we have now become acquainted with may also 
be applied to necrosis in flat and spongy short bones ; but at the same 



DETACHMENT OF THE SEQUESTRUM. 



489 



time we must remark that in necrosis of these bones the new forma- 
tion is much less, often entirely wanting, because the inflammation 
here is particularly of constitutional origin, and hence occasionally 
deviates from the normal course ; as a rule, the inflammatory neo- 
plasia in necrosis of the spongy bones soon assumes the ulcerative 
character, and then the formation of new bone is but slight ; more- 
over, acute, non-traumatic periostitis is something very rare in spongy 
bones. 

Extensive necrosis may even occur after originally pure ossifying 
periostitis and ostitis, in case the newly-formed ossific deposit is re- 
absorbed, suppurates and decomposes at the point of its attachment 
to the diseased bone ; this gradually affects the nutrition of the bone ; 
it often continues to live for a long time in the medullary cavity, or 
rather leads a half existence between living and dying ; this variety 
of periostitis and necrosis occurs especially in the maxillary bones 
after chronic poisoning by phosphorous fumes, a disease peculiar to 
workers in match-factories. I cannot enter more minutely into this 
phosphorous periostitis and necrosis, which has many noteworthy 
peculiarities, because it would be necessary to load you with too 



Fig. SO. 




1. Scapula of a young- dog 150 days after the removal of the delineated fragment, which at the time of the 

resection formed part of the fully-ossified portion of the scapula; the articular surface, edges of the 
cartilage, and the carefully-detached periosteum, were all preserved. The growth of the bone was 
unimpeded, and there was almost complete regeneration of the resected portion. 

2. Scapula of a young- dog of the same litter, 150 days after an operation performed the same day as the 

above, and in the same manner, except that the periosteum was removed. The growth was im- 
paired, and the resected portion was not regenerated. 



490 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

many details, which would now confuse you. If you bear in mind 
the above-described course of necrosis in the hollow bones, you will 
have the opportunity of learning in the clinic all the deviations that 
may occur in any case, from peculiar circumstances, for necrosis is a 
relatively frequent disease of the bones. 

I cannot leave the anatomy of necrosis and the regeneration of 
bone accompanying it, without mentioning an excellent French 
worker who has spent many years in the study of the osteoplastic 
power of the periosteum, and has nobly carried forward the previous 
works of Troja, Flourens, B. Seine, A. Wagner, and others, on this 
subject : I mean Oilier, who, with untiring zeal, has pursued this study 
experimentally and clinically, and has closed it up for a long time ; I 
have repeated part of his experiments, and can only confirm the idea 
that under certain circumstances, in young animals, preservation of 
the periosteum decidedly favors the reproduction of bone. In the 
course of these lectures I have already stated my opinion regarding 
the osteoplastic power of human periosteum, especially as compared 
with other soft parts surrounding the bones, and hitherto I have found 
these views confirmed by every new experience. 

Quite recently <T. Wolff, who was already distinguished by his 
careful provings of Ollier's experiments, has advanced some entirely 
new and interesting views on the growth of bone. 



We now pass to the symptoms and diagnosis of necrosis. Dis- 
ease of the bone is called necrosis from the time it becomes evident 
that a part or the whole of a bone is dead, till the sequestrum is re- 
moved ; the subsequent healing of the cavity in the bone is usually a 
simple development of healthy granulations with suppuration, which 
may, it is true, assume an ulcerative character. Now, the question 
arises, How shall we know that a part is necrosed? This may be 
very simple in some cases, especially where the necrosed bone is 
exposed, that is, in all cases where necrosis follows uncovering of the 
bone; the dead bone looks quite white, but in some places it be- 
comes blackish, like other dried, necrosed parts. Gangrene of the 
bone, as far as regards the bone-substance, may remain as dry gan- 
grene ; the soft parts in the bone, the vessels, connective tissue, and 
medulla, may, however, like other soft parts, be attacked by dry or 
moist gangrene ; perfect dryness occurs in most cases where the bone 
is uncovered, exposed to the air ; hence this superficial necrosis is 
rarely a process of decomposition, seldom accompanied by bad smells. 
In deeply-situated necrosis, as in that of a whole diaphysis or of a 
sawed or fractured surface, which is embedded in soft parts, there is 



FATE OF THE SEQUESTRUM. 491 

usually decomposition of the medulla ; the smell from a large ex- 
tracted sequestrum is occasionally very penetrating. This decom- 
posing medullary substance is dangerous as long as no line of 
demarcation has formed, while the lymphatic vessels of the vicinity 
are still open ; when the proliferation of tissue has occurred in the 
borders of the bone next the healthy parts, the inflammatory neopla- 
sia forms a wall through which reabsorption does not readily occur. 
How are we to recognize a deeply-situated sequestrum? This can 
only be exactly done by the probe. Through the opening from which 
the pus flows we pass a probe, as large a one as possible, with which 
we feel the surface of the sequestrum, which is usually smooth and 
firm, more rarely rough and soft. We attempt to slide the probe 
along it, to determine the length of the sequestrum ; we also press the 
probe firmly against the sequestrum, to find whether it be movable, 
detached, or whether it be still firm ; as you will understand, this is 
important in relation to the question whether we may as yet attempt 
extraction of the sequestrum. A further aid to diagnosis is the in- 
creased thickness of the extremity; we feel the extensive new for- 
mation of bone ; thick yellow, often mucous, pus flows from the 
openings; the bone is not especially sensitive to pressure; nor is 
careful probing usually painful, although the patient often dreads it, 
because some surgeons do it with unnecessary violence, but without 
any result. The patient is free from fever. 

From these points you will readily diagnose many cases of ne- 
crosis ; as long as there are no external openings, the diagnosis of cen- 
tral necrosis of a bone is liable to error. Caries is almost the only 
thing for which necrosis can be mistaken ; the mode of origin and 
the locality aid greatly in the distinction, for necrosis occurs more 
frequently as a result of acute inflammation in the hollow bones 
(femur ', tibia, humerus), caries usually occurring more slowly in 
spongy bones ; however, the objective symptoms are also different : 
in caries there is but little formation of new bone about the ulcer, 
often none can be felt ; in necrosis this is extensive : in caries the pus 
is thin, bad, serous ; in necrosis it is thick, often good, frequently mu- 
cous : in caries we pass the probe into rotten bone, and probing is 
usually quite painful ; in necrosis the probe generally strikes on the 
firm sequestrum and is not often painful. From this comparison of 
the symptoms, which result from the different natures of the two dis- 
eases, you must acknowledge the possibility of a diagnosis ; in many 
cases, indeed, it is very easy and simple. In other cases, the anatom- 
ical conditions are more difficult to understand ; when necrosis and 
caries occur together, all the symptoms, except feeling the sequestrum 
on probing, are in favor of caries. In central caries of the hollow 



492 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

bones, enormous thickening of the bone occurs in exceptional cases, 
at the same time the inner wall of the bone-cavi ty may feel very firm 
and hard, like a sequestrum ; these cases may give rise to error : on 
opening the cavity, no sequestrum is found, as had been expected ; it 
is possible that in these rare cases the sequestrum may have been very 
small and may have been absorbed ; of this more hereafter. But these 
exceptional cases do not disprove the rule ; hence you may, to a great 
extent, confide in the above comparative diagnosis. 

Now, a few words about the fate of the sequestrum. Do you 
mean to say the dead bone cannot be reabsorbed ? Have I not told 
you frequently that dead bone may be dissolved and consumed by the 
granulations ? Hence we should expect that the elimination of the 
sequestrum would not require any aid. From my observations, I have 
no doubt that small sequestra may be completely consumed by prolif- 
erating granulations ; granulations that are being destroyed or under- 
going cheesy degeneration have no power of dissolving bone ; we 
have already stated, when speaking of caries, that partial necrosis oc- 
curs so readily in atonic suppurative or caseous ostitis, just because 
the inflammatory neoplasia, which so quickly breaks down again, does 
not dissolve the bone, but leaves it to be macerated in the body. But 
the reabsorption of the sequestrum has its limits : first, of course, it 
ceases where the bone is uncovered, for here the granulations have no 
effect; it also ceases as soon as they secrete pus on their surface; 
hence a sequestrum, resulting from acute periostitis, is not usually 
absorbed at the point where the periosteum suppurates and where pus 
forms during the whole process, because it does not come in contact 
with the granulations ; but at all points where the sequestrum must 
be loosened, reabsorption commences from the interstitial granulation- 
masses forming on the bone ; lastly, after the sequestrum is detached, 
if these granulations also produce pus, reabsorption ceases here also, 
and the sequestrum bathed in pus ceases to decrease; the granula- 
tions of the pus-cavity, growing from all sides toward the sequestrum, 
in the course of time undergo chemical change ; they become very 
gelatinous, mucous, and often undergo fatty degeneration. 

But the sequestrum must finally come out. Can it do so un- 
aided ? This does occur ; whence the power that pushes it out ? Let 
us suppose a central necrosis ; a sequestrum becomes detached from 
all sides; then, for the reasons above mentioned, it is considerably 
smaller than the cavity in which it lies ; the piece of bone is now 
quite loose ; granulations grow toward it from all sides except from 
the one where the pus-cavity opens externally ; here there is no re- 
sistance ; if the opening be large enough, the constantly-increasing 
granulations push out the sequestrum. But for this to occur there 



SEQUESTROTOMY. 493 

must be certain mechanical conditions which are rarely fulfilled ; small 
sequestra are often thrown off spontaneously ; large ones, which can- 
not pass the existing openings, must be removed artificially. 

The treatment of necrosis at first consists simply in keeping the 
fistulas clean. Chemical solution of the sequestrum is not to be 
thought of. If you were daily to pour muriatic acid into the fistulous 
opening, it would affect the newly-formed osseous tissue as much as, 
or more than, it would the sequestrum, which would be very unfortu- 
nate, as it must replace the latter. Hence the mechanical removal 
of the sequestrum is the only thing left ; this should not be attempted 
before complete detachment. This is a very important rule : first, be- 
cause the dead bone can rarely be sawed out without removing a good 
deal of the healthy and of the newly-formed bone, both of which are 
bad ; and, secondly, because the new bone is rarely firm enough before 
the sequestrum is detached. Here, again, we meet a wonderful pro- 
vision of Nature : the sequestrum is not generally detached till the 
new formation of bone is strong enough to replace the lost portion of 
bone. This beneficent provision should not be brought to naught by 
meddlesome interference. There are only a few special exceptions to 
the above rule, especially in necrosis from phosphorus, which is not 
a pure necrosis, but is often combined with caries ; but of this we 
shall treat more particularly in special surgery and in the clinic. 

I have already told you that we may sometimes tell by the probe 
whether a sequestrum is detached ; but this is not always so ; it may 
be so shut in by granulations that it cannot be felt to move. It is 
always hard to decide on the mobility of a large sequestrum ; and the 
curved shape of the bone (as of the lower jaw) may greatly interfere 
with the decision. In such doubtful cases the duration of the pro- 
cess, and the thickness of the bony case, are important aids in deter- 
mining whether the sequestrum be detached or not. Most sequestra 
are usually detached in eight or ten months ; in a year even an 
entire necrotic diaphysis usually lies as a loose sequestrum in the 
newly-formed bony case. These are approximate determinations, 
which may of course have exceptions. If the formation of bone be 
still weak, and nevertheless the sequestrum be already detached, it 
is well to postpone the extraction in the humerus, tibia, and femur, 
so that the formation of bone may be firmer, provided the general 
health does not suffer. Should albuminuria begin, the extraction 
should be hastened. 

Extraction of the sequestrum, especially when it requires prelimi- 
nary enlargement of the cloaca (fistulas leading into the bony case), 
is called the operation for necrosis or sequcstrotomy. This operation 



494 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

may be very simple. If one of the openings of the bony case be 
tolerably large, and the sequestrum small, we may pass a good pair 
of forceps through the opening and try to seize and remove the se- 
questrum. If, as in caries necrotica, there be no formation of new 
bone, we enlarge the fistulous opening through the soft parts with 
a knife, and remove the necrosed piece of bone. But, if the openings 
be small and the sequestrum large, a portion of the bony case must 
be removed, both for the purpose of introducing instruments for ex- 
traction and for removing the sequestrum. In rare cases, it is suffi- 
cient to enlarge one opening with trepan, chisel, and hammer. I 
usually do the operation as follows : With a stout knife I make an in- 
cision through the soft parts down to the bony case, from one fistulous 
opening to an adjacent one ; then, with a handled scraper, a raspa- 
torium, I draw the thickened soft parts from the rough surface of the 
bony case, so as to expose it to a certain extent. This exposed por- 
tion should now be removed, to make an opening through which the 
sequestrum may be removed. For this purpose we may use saws of 
various kinds — the osteotome, the panel-saw, etc. ; of late, I always 
employ chisel and hammer ; the work is laborious, use what instru- 
ments we will. The portion of the bony case removed should be as 
small as possible, so as to interfere the less with its firmness. When 
the case is opened, the sequestrum is exposed ; we attempt its removal 
by elevators or with strong forceps ; this also is sometimes very trouble- 
some. When the removal is accomplished, the indication is fulfilled. 

If, contrary to expectation, the sequestrum be found not detached, 
we should avoid forcing it out, but wait a few weeks or months, till 
we are satisfied of its detachment. After the operation, the suppu- 
rating cavity in the bone is to be kept clean ; the patient should keep 
his bed for some time ; most fistulas soon cease discharging, but it is 
still some time before the sequestrum-cavity is filled with ossifying 
granulations. We cannot do much to hasten this, and the fistulas, 
which sometimes remain a long while, usually cause so little trouble 
that we are not often called on to do any more operations for them. 
Occasionally, however, too large an opening remains for a long time, 
its walls become sclerosed and cease to granulate ; here we apply the 
treatment for atonic ulcers of the bone. In these old cases, the hot 
iron to the cavity in the bone, and chiselling out the track of the fis- 
tula, is the only treatment from which I have ever seen any benefit. 
Many cases of these bone-fistulas are incurable. 

The full value of sequestrotomy has only been appreciated for the 
past ten years ; it first became common after the introduction of 
chloroform, for it is a terrifying operation. This chiselling, sawing, 
and hammering on the bones, are horrible for a looker-on, and the more 



RACHITIS. 495 

so as the operation may last some time ; amputation is a trifle in 
comparison. Local anaemia (as induced by EsmarcWs bandage) 
greatly facilitates the recognition of the anatomical conditions in 
these operations. Formerly amputations were frequently performed 
for total necrosis, a thing that no surgeon would do now. Hence, in 
old museums, you find the most beautiful preparations of extensive 
necroses ; now these are rarely found, because almost all sequestra 
are removed at the proper time. Locally the operation is quite ex- 
tensive, but the febrile reaction is usually slight. Severe as the in- 
flammatory symptoms and fever might be if you were to treat a 
healthy bone in the same way, the effect on the bony case of the 
sequestrum is but slight. From my own experience, I do not know 
of a case which, after such an operation, even where the entire bony 
case was opened in total necrosis of the tibia, turned out badly ; 
and I am satisfied that the operation for necrosis is one of the most 
successful of operations, and that by it many lives are saved, such as 
were formerly lost from amputation, from constitutional diseases due 
to continued suppuration from the bone, or from fatty degeneration 
of internal organs, morbus Brightii, and tuberculosis. 



LECTURE XXXVI. 

APPENDIX TO CHAPTEE XVI. 

Rachitis : Anatomy, Symptoms, Etiology, Treatment.— Osteomalacia.— Hypertro- 
phy and Atrophy of Bone. 

Rachitis and Osteomalacia. — We must still touch on two consti- 
tutional diseases, which are chiefly manifested in certain changes of 
the bone, namely, softening. They are called rachitis and osteoma- 
lacia. Their effects in changing the form of the bone are much 
alike, but their natures differ somewhat. They cannot be exactly 
classed among the chronic inflammations, although nearest related 
to this process. 

Let us begin with rachitis. The name comes from pa%ic, the 
backbone, and properly signifies inflammation of the spine ; but the 
vertebrae rarely suffer much in rachitis ; hence the origin of the name 
is not very clear; subsequently it was often called "English dis- 
ease," because it was particularly well known to English writers, 
and probably also was especially frequent in England. 

The essence of the disease consists in deficient deposit of chalky 
salts in the growing bone, and remarkable thickness of the epi- 
physeal cartilages. You will already see that this disease is peculiar 



496 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

to childhood; it is a disease of the development of bone, which how- 
ever usually aifects so many bones that it must be regarded, not as 
a local, but as a constitutional disease, which you may reckon among 
the dyscrasiae already known to you. The insufficient deposit of 
chalky salts in the growing skeleton in rachitis is accompanied by 
unusual development of vessels and unusual absorption of the bony 
tissue already developed (during the growth of bone there is always 
a slight amount of absorption at the inner and outer surface of the 
cortical layer), as well as unusual proliferation of the epiphyseal car- 
tilages ; if you remember also the young osteophytes forming on the 
outsides of the hollow bones, it must be acknowledged that this dis- 
turbance of nutrition can scarcely be distinguished from inflamma- 
tion, even if it passes on to suppuration and caseous degeneration. 
We often find rachitic symptoms in scrofulous children, and some 
physicians regard the disease as one symptom of scrofula ; but this 
is not quite correct, for in many rachitic children we find no traces 
of scrofula, among w T hich are especially reckoned tendency to swell- 



Fig. 91. 




Typical illustrations of rachitic malformations of the leg. 



ing of lymphatic glands, suppuration, and caseous degeneration. 
Moreover, the rachitic process has little anatomical connection with 



RACHITIS. 497 

the forms of periostitis and ostitis that we have studied in scrofulous 
children, for it never leads to caries. The disproportion between 
the growth of the bone and deficient impregnation of its tissue with 
chalky salts results in lack of firmness of the bones ; consequently 
they bend, especially those that bear the weight of the body. Where 
the bones are very soft, muscular contraction also acts on them so as 
to induce curvature. These curvatures are most common in the 
lower extremities; the femur bends anteriorly and inwardly, the 
bones of the leg bend anteriorly and outwardly or inward. The tho- 
rax is compressed laterally so that the sternum projects sharply, and 
the result is the so-called chicken-breast {pectus carinatum). In 
high grades of rachitis there are also distortions of the pelvis, spinal 
column, and upper extremities. In such children the occiput long 
remains soft and compressible, and dentition is delayed. Sometimes 
the softness of the occiput is the sole symptom of rachitis, so that 
this has even been regarded as independent of the general rachitic 
disturbance. According to Virchoio, the distortion of the upper 
extremities depends mostly on a number of small curvatures (infrac- 
tions) of the entire bone, or of parts of the cortical layer. Complete 
fractures rarely occur ; if they do, the bone is again united firmly by 
callus, under the ordinary treatment. 

Rachitis causes other changes in the bone besides these deformi- 
ties, namely, thickening of the epiphyses and of the point of union 
between the costal cartilages and the bony ribs. The thickening of 
the epiphyses may be so great, at the lower end of the radius, for 
instance, that above the wrist, at the point just above the epiphy- 
seal cartilage, there is a second depression in the skin ; this appear- 
ance of the joint has given rise to the term " double-jointed ; " the 
nodular thickenings on the anterior ends of the ribs are often very 
remarkable, and, as they lie regularly under one another, they have 
been called the " rachitic rose-garland." If these changes in the bone 
have taken place, there is no hesitation in diagnosing rachitis ; before 
they have become evident, the diagnosis is doubtful. It is true, there 
are some prodromal symptoms : voracious appetite, pot-belly, disin- 
clination to standing and walking ; but these symptoms are always 
too undecided to permit any definite conclusion. The disease most 
frequently begins in the second year, and attacks well-nourished or 
even fat children ; indigestion and inclination to constipation occur 
occasionally, but not always. We know little of the exciting causes 
of rachitis ; here in Germany it is about equally frequent in all classes 
of society ; hereditary influence may have some effect ; we may sus- 
pect, but cannot prove, a disturbance in the composition of the blood, 
in the assimilation of nutriment. In regard to the course of the dis- 
32 



498 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

ease, under proper treatment it often subsides quickly ; that is, the 
symptoms of distortion of the bone cease, or rather do not increase; 
the children, who had ceased to walk, again desire to do so. As the 
normal growth of the bone goes on, the distortions become less per- 
ceptible, and often disappear entirely ; this may be readily under- 
stood from the nature of the growth of the bone. Before the bones 
again acquire their normal consistence, at the end of the rachitic 
process, there is usually an abnormally rich deposit of bone, so that 
in certain stages the rachitic bones are abnormally hard and firm ; 
that is, in a sclerosed state. Rarely, rachitis lasts till the skeleton 
has attained its growth, and these cases furnish the excessive distor- 
tions and dislocations that are usually presented as types of this dis- 
ease. In every pathological anatomical collection you find examples 
of such rachitic skeletons. 

The greater my experience, the more I am inclined to regard flat 
foot, genu valgum and varum, as well as lateral curvatures of the 
spine (scoliosis), as being due to weakness of the bones, which can- 
not be distinguished from a mild form of rachitis. This localized 
rachitis comes later in life, it is true, but it is generally between ten 
and twenty years, while the disease briefly termed rachitis, as above 
stated, is mostly seen in very young children ; still both cases are 
due to the bones remaining soft and to pliability of growing bones, 
besides which various other causes must act to induce the above- 
mentioned distortions. 

Hereafter you will often hear that some physicians think there is 
a direct relation between rachitis and infantile diseases of the brain, 
especially paralyses, spasms, and psychical disorders. I will not deny 
that this rather obscure disease may directly affect the development 
of the brain, but in most cases it does so indirectly. The rachitic 
process in the cranial bones is often followed by rapid sclerosis, by 
such formation of new bone that even the cranial sutures may ossify; 
this interferes with the regular growth of the skull, which becomes 
irregular, and here and there too small for the growing brain, and 
thence arise functional disturbances of the brain. 

Rachitic children are rarely brought to the doctor before the 
parents notice the thick limbs or distortion, or until, as the mother 
expresses it, " they are off their legs," i. e., they no longer wish to 
stand or walk, as they formerly did ; the disease is so common and 
so well known that often it needs no surgeon for its recognition. 
As a rule, treatment has only one indication, that is, to remove the 
diathesis ; hence it is chiefly medical, and especially dietetic. Re- 
garding the latter, the patient should avoid too free use of bread, 
potatoes, mush, and flatulent vegetables ; he should freely consume 



RACHITIS. 499 

milk, eggs, meat, and good white bread, and should take strengthen- 
ing baths of malt, herbs, etc. Internally we should prescribe cod- 
liver oil, iron, and similar strengthening and tonic remedies. We 
might think of giving preparations of lime, but they are so indigest- 
ible, and are so quickly excreted by the urine, that they do no good : 
they have almost been thrown aside; it is possible, also, that rachitis 
is essentially a disease of digestion, in which the preparations of lime 
are, from some unknown cause, not absorbed. It is rather a one- 
sided view to suppose that in rachitis or osteomalacia lack of supply 
of lime is the cause of absence of deposit of chalky salts in the 
bones, of the disappearance of that which has been deposited. It is 
also possible that lime entering the stomach, from faulty digestion, 
does not reach the blood, or that it is excessively excreted by the 
kidneys, or perhaps the newly-formed bony tissue does not take up 
the chalky salts brought to it in normal or even in excessive amounts. 
It is true, these points furnish no direct indications for treatment, 
but I mention them so that you may see that we are not physiologi- 
cally justified in referring the disturbed nutrition solely to deficient 
supply. Frequently the parents ask for splints to remove the curva- 
tures, or, at least, prevent their increase; they will also ask you 
whether the children should be urged to walk, or permitted to lie 
still. On this point it is best to let children have their own way : 
if they do not wish to go, do not urge it ; if they lie still more than 
they run about, they should be kept in the open air as much as 
possible ; taking children from a damp city dwelling to the country 
often suffices for the cure of rachitis. Splint boots and similar ap- 
paratuses, that load the feet, should only be applied in cases of ex- 
cessive curvature, where the position of the feet mechanically inter- 
feres with walking ; this state of affairs is rare, hence the indication 
for such orthopedic apparatus is limited. 

When the rachitis has disappeared, such amount of curvature may 
remain in rare cases as to require some treatment ; in the great ma- 
jority of cases this is unnecessary, since, as already stated, the cur- 
vatures spontaneously disappear with the growth of the skeleton. 
Only in the leg curvatures sometimes remain, so that the foot is dis- 
torted, and only its inner or outer border can be placed on the floor ; 
if this remains for years at the same point, an attempt should be 
made at straightening. This may be done in two ways.. We anaes- 
thetize the child, and carefully fracture the bone subcutaneously ; 
have the leg held straight, apply a plaster-bandage, and treat the 
injury as a simple fracture ; recovery usually takes place readily. 
In some cases, however, after the rachitis has run its course, the 
bone is so very firm that this breaking does not succeed. Then sub- 



500 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

cutaneous osteotomy, according to J3. von Langenbeck (p. 230), is in- 
dicated. The results of this operation, which I have had to make four 
times, have so far been very satisfactory ; in one of these cases the 
skin-wound healed by first intention, and the subsequent treatment 
was that of simple fracture. The operation will always remain a rare 
one, because these excessive rachitic distortions are themselves rare. 



Now, a few words about osteomalacia , bone-softening, kclt' eBoxfjV. 
The disease only occurs in adults, and is also characterized by distor- 
tion of the bones ; but here there is an actual reabsorption of exist- 
ing bone. In the hollow bones the medulla gradually assumes the 
preponderance, while the cortical substance becomes thinner and 
thinner, and consequently the bones weaker and more flexible; and 
finally there may be a complete absorption of the bone, so that little 
is left besides the periosteum, which participates rarely, and then 
but little, in the disease, scanty osteophytes growing from it. The 
spongy bones also grow weaker, the trabecule thinner, and become 
so soft that they shrink. The medulla appears reddish and gelati- 
nous, but does not, as in fungous caries, consist solely of granulations; 
it contains much fat. The microscopic appearances in this process 
have already been described in ostitis malacissans. Lactic acid has 
been found in the medulla of the hollow bones, so that it is very 
probable that the bones are dissolved by it. The lime going into the 
blood is often excreted in the urine as oxalate of lime. So you see 
that this is an ostitis malacissans with nothing peculiar in its anato- 
my, but which owes its distinction to its affecting many bones simul- 
taneously, often occurring under peculiar conditions, and never lead- 
ing to suppuration or caseous degeneration. 

Concerning the etiology of the disease we know but little ; osteo- 
malacia is particularly frequent in some parts of Europe, and among 
women ; it attacks the latter more particularly while in the puerperal 
condition ; occasionally it is preceded by drawing pains and soreness 
on moving, which continue through the disease. The distortions 
occur chiefly, primarily, even solely, in the pelvis, which assumes a 
peculiar, laterally-compressed form, of which you will hear more in 
obstetrics. This is followed by curvature of the spine and lower ex- 
tremities, with muscular contractions. The disease may pause, and 
exacerbate with a new pregnancy, etc. Slight grades and localized 
forms of osteomalacia, as that of the pelvis, not unfrequently recover 
spontaneously ; if the disease be of a high grade, general marasmus 
occurs, and the patient dies. The treatment is the same as in rachitis, 
but the hopes of success are less. 



OSTEOMALACIA. 



501 



The cases of local osteomalacia or osteoporosis, which often accom- 
pany caries, are- more interesting to us than the above-described gen- 
eral osteomalacia. I will relate you a case that will at once explain 
what I mean : A woman, about forty years old, was brought to the 
hospital for extensive caries of the knee-joint ; she was excessively 



Fig. 92. 




Woman with excessive osteomalacia, after Morand. The bones consist mostly of membranous cylin- 
ders, or very thin layers of bone. 



marasmic, and 



died the following day. On autopsy we found com- 
plete fatty degeneration of the liver, spleen, and kidneys ; in the knee 
the condyles of the femur and tibia were extensively destroyed by the 
carious process. I sawed off the lower end of the femur to remove 
the preparation, and found that it was very much thickened ; the cor- 
tical layer measured scarcely half a line ; the medulla was reddened, 
and resembled that in osteomalacia ; the thinning extended upward 
to the trochanter. I examined the tibia of the diseased leg, the femur 
of the healthy one, and the pelvis, and found them all perfectly normal ; 
that is, only the femur of the diseased leg was osteomalacic. In the 



502 CHRONIC INFLAMMATION OF THE PERIOSTEUM, BONE, ETC. 

same way I once found the lower half of the tibia affected with osteo- 
malacia, in caries of the ankle. There was apparently the same thing 
in a child that had the head of one femur removed for caries of the 
hip-joint. I assisted in this operation ; as I was on the point of lift- 
ing the thigh and rotating it outward to aid the operator, the thigh 
broke through the middle, right in my hands ; a plaster-bandage was 
applied, and the fracture recovered ; the child was completely restored. 
In other cases, however, after fractures of bones with osteomalacia, in 
the so-called fragilitas ossium, pseudarthroses are apt to remain. 



I will also mention hypertrophy and atrophy of bone, which, how- 
ever, have more anatomical than clinical interest. 

Anatomically we may call any bone hypertrophic which is enlarged 
in length or thickness. There are very few cases where single hollow 
bones, as one femur or one tibia, are excessive in length, and give 
rise to inequality of the extremities ; for this excessive growth I ac- 
cept the name " hypertrophy of bone," or, better, " giant-growth " 
(" riesenwuchs ") ; still, to give this term to every thickening or scle- 
rosis would be of no practical value, although anatomically correct, 
because these conditions of the bone may depend on very different 
morbid processes, partly active, partly completed. Even more indefi- 
nite is the term atrophy -of the bone ; occasionally, a carious, osteo- 
malacial, or a half-destroyed bone, etc., is thus designated. This is of 
no practical value ; we do not mean to deny that there may be atrophy 
of the bone without a true morbid process. Senile atrophy, as of 
alveolar process of the jaw, is a striking example of this. Here the 
term atrophy of bone may be retained ; in most other cases it would 
be better to name the process that has induced the atrophy. 



CHAPTER XVII. 
CHRONIC INFLAMMATION OF THE JOINTS. 



LECTURE XXXVII. 

General Eemarks on the Distinguishing Characteristics of the Chief Forms. — A. Fun- 
gous and Suppurative Articular Inn animations (Tumor Albus), Symptoms, Anato- 
my, Caries Sicca, Suppuration, Atonic Forms.— Etiology. — Course and Prognosis. 

In more than half the cases of chronic inflammation of the joints, 
the synovial membrane is the part first affected ; this affection may 
be accompanied by more or less secretion of fluid, and this fluid may 
be purely serous or purulent. Chronic serous synovitis (hydrops 
articulorum chronicus), unless from some external cause, is no more 
apt to become purulent synovitis than is chronic articular rheumatism, 
But other forms of chronic inflammation of the joints may be accom- 
panied by suppuration from the first, or else may be characterized by 
the formation of numerous granulations. The two chief groups of 
chronic articular inflammation are characterized by the condition of 
the synovial membrane even more than by the quality of the fluid 
contained in the joint ; when the secretion is purely serous, the syno- 
vial membrane is somewhat thickened, it is true ; the tufts are en- 
larged, and their apices are somewhat more vascular than normal, 
still these changes are never so extensive as to greatly injure the 
membrane ; but in the other variety of chronic inflammation the mem- 
brane changes greatly, and is gradually transformed into a spongy 
(fungous) mass of granulations, which often, but not always, produces 
pus, opens outwardly (fistula, cold abscess), causes distortion of the 
cartilages and bones, and may thus induce peripheral caries of the 
epiphysis. This latter group, which has several subvarieties, we shall 
term fungous and suppurative inflammations of the joints ; they form 
the great majority of all articular inflammations, and hence will occupy 
our attention for some time. For a more exhaustive account of joint 
diseases, I refer you especially to the excellent works of Bonnet, Volk 
mann, and Hueter. 



504 CHRONIC INFLAMMATION OF THE JOINTS. 

A. THE FUNGOUS AND SUPPURATIVE ARTICULAR INFLAMMATIONS. 

(TUMOR ALBUS). 

Tumor albus (white swelling) is an old name which was formerly 
applied to almost all swellings of the joints that ran their course with- 
out redness of the skin ; now it has been agreed only to give this name 
to the affection we are about to describe, which is also, with more or 
less correctness, termed scrofulous inflammation of the joint y but of 
this later. 

The disease is very frequent in childhood, particularly in the hip 
and knee joints ; it usually begins very insidiously, more rarely sub- 
acutely. If the knee-joint be affected, the parents usually first notice 
a slight dragging or limping of the lame leg ; the child, either volun- 
tarily or on questioning, complains of pain after walking some dis- 
tance, and on pressure over the joint ; about the knee itself the laity 
can see nothing out of the way. On comparing both knees, the sur- 
geon will find, even quite early in the disease, that the two furrows 
which normally run alongside of the patella, when the limb is ex- 
tended, and give the knee-joint its shapeliness, have either disappeared 
on the affected side or at least are shallower than on the sound side ; 
except this there is nothing observable. The hinderance to walking is 
so slight that children go about with a slight limp for months, and 
complain so little that it is some time before the parents feel obliged 
to consult a surgeon ; they often delay doing this till, after continued 
exertion, the limb has begun to pain and swell more. The swelling, 
which was at first scarcely perceptible, is now quite evident; the 
knee-joint appears evenly round and quite sensitive to pressure. If 
we suppose that no treatment be instituted, but the disease left to 
itself, its course is about as follows : The patient continues to limp 
around for a few months, but finally the time comes when he cannot 
walk ; he is obliged to lie down most of the time, because the joint is 
so painful ; gradually it becomes more and more angular, especially 
after each subacute exacerbation. Now, certain parts of the joint, at 
the inner or outer side, or in the hollow of the knee, become more 
painful ; there is evident fluctuation at some one of these points ; the 
skin grows red, and finally suppurates from within outward, and is 
perforated after a few months ; a thin pus, mixed with fibrinous cheesy 
flocculi, escapes. Now the pain decreases, the condition improves ; 
but this improvement does not last long ; a new abscess soon forms, 
and so it goes on. Meantime, perhaps two or three years have 
elapsed, the general health of the patient has suffered; the child, 
which was previously strong and healthy, is now pale and thin ; the 
opening of the abscesses is not unfrequently accompanied or followed 
by fever ; this fever exacerbates as each new abscess develops ; this 



TUMOR ALBUS. 



505 



exhausts the patient ; he loses his appetite, digestion is impaired, 
diarrhoea comes on, and the emaciation is increased from week to 
week. Even at this period the disease may spontaneously subside, 
although this rarely happens ; more frequently it proves fatal, from 
the exhaustion caused by the suppuration and continued hectic fever. 
Should recovery take place, it is announced by decrease of the sup- 
puration, retraction of the fistulous openings, improvement of the 
general health, increased appetite, etc. ; finally, the fistulae heal, the 
joint remains angular or distorted in some way, the pain ceases, and 
the patient escapes with his life and a stiff leg ; this termination of 
chronic suppuration of the joint in anchylosis (stiff-joint) is the most 
favorable that can occur when the disease has been severe ; the anchy- 
losis may be complete or imperfect, i. e., the joint may be perfectly 
stiff or slightly movable; the whole process may have lasted from 
two to four years. 26 Among the local symptoms I must add that, from 
long disuse of the limb, the muscles have become much atrophied 
from fatty degeneration and cicatricial contraction, the latter occurring 
especially in the vicinity of long-suppurating abscesses. The capsule 
of the joint also, which was much infiltrated and swollen, as well 
as the surrounding ligaments, is contracted, particularly on the side 
toward which the joint was bent; hence in the knee-joint this con- 
traction would be greatest toward the hollow of the knee. 

This short description may serve you for a general type of the 
disease in question, and of its importance ; to enable you to under- 
stand the various forms in which it may appear, it seems advisable to 
first give you a clear description of the anatomical changes in these 
diseases of the joint. We have the opportunity of observing the dif- 
ferent stages of these changes in exsected joints, in amputated limbs, 
and on the dead body. I have paid so much attention to this subject, 
that from my individual observations I can give you a very accurate 
account of the anatomical changes. These are much alike in all cases, 
and, from what you already know about chronic inflammations of other 
parts, you will anticipate that there is in reality only a variation of the 
old story of serous and plastic infiltration with various grades of vas- 
cularization, of proliferation, and destruction, etc. 

Let us first with the naked eye study these joints in various stages 
of the disease. Let us suppose the common case of the affection be- 
ginning with chronic synovitis : we first find swelling and redness of 
the synovial membrane ; it has already undergone some change in the 
lateral portions of the joint, in the folds, and neighboring sacs ; its 
tufts are puffed up, very little elongated, but very soft and succulent ; 
the whole membrane is more readily distinguished from the firm tissues 
of the capsule, and may be detached with greater facility than normal- 



506 CHKONIC INFLAMMATION OF THE JOINTS. 

ly. At this time the synovia is rarely increased, but is cloudy, or even 
resembles muco-pus. These changes in the synovial membrane gradu- 
ally increase; it becomes thicker, more oedematous, softer, redder; the 
tufts grow to thick pads, and in places resemble spongy granulations. 
The surface of the cartilage loses its blue lustre, though it is not yet 
visibly diseased ; but the synovial outgrowths begin to grow over the 
cartilages from the sides, and to push in between the two adjacent 
surfaces of cartilage ; meantime the capsule of the joint is also thick- 
ened, and has acquired an evenly, fatty appearance, and is very oedema- 
tous ; this swelling and oedema gradually extend to the subcutaneous 
tissue, and to the skin. From this point, the changes in the cartilage 
claim most of our attention. The synovial proliferations, in the shape 
of red granular masses, advance gradually over the entire surface of 
the cartilage, and cover it completely, lying over it like a veil (Fig. 93) ; 

Fig. 93. 




Diagram of a section of a knee-joint (the interarticular cartilages have been left out, the ar- 
ticular cartilages shaded) with fungous inflammation : a a, fibrous capsule ; J, crucial liga- 
ment ; c, femur ; d, tibia ; e e, fungous synovial membrane growing into the cartilage, at/ it 
even grows into the bone ; at g are isolated prolifications of the granulations into the 
bone on the border between bone and cartilage. 

if we attempt to remove this veil, we find that in some places it is 
attached quite firmly by processes entering the cartilage, just as the 
roots of an ivy-vine cling to and insert themselves into the wall 
against which it grows (as is also the case in pannus of the cornea) ; 
these roots not only elongate, they spread out, and gradually eat up 
the cartilage, which, when the covering of fungous prolifications is re- 
moved, appear first rough here and there, then perforated, and finally 
disappear altogether ; then the fungous prolification extends into the 
bone, and commences to consume this ; the result is fungous caries, as 



TUMOR ALBUS. 507 

we have already learned; as a result of the changes from chronic 
inflammation, the bone is destroyed in the manner before described, 
and here you have the whole course and the relation of fungous in- 
flammation of the joint to caries. The morbid process advances un- 
equally ; one condyle of a joint may be almost consumed while another 
partly preserves its cartilaginous surface. The other parts of the sy- 
novial membrane may also proliferate outwardly toward the capsule ; 
capsule, subcellular tissue, and skin, are transformed at one place or 
another into fungous granulations, with or without suppuration, and 
thus we have external openings, and fistulse, which either communicate 
directly with the joint, or with a synovial sac. 

Here let us stop a moment to notice what may be seen with the 
microscope at the affected part ; on this point I can give* you least 
that is new. The normal synovial membrane consists of loose con- 
nective tissue with moderately rich capillary net-work, which forms 
complicated folds in the tufts ; on the surface of the membrane there 
is a simple layer of endothelium, composed of flat polygonal cells, just 
as there is on most serous membranes. The tissue of the membrane 
is gradually permeated with cells, becomes softer, loses its firm, fibrous 
character, and the vessels dilate and increase decidedly. The en- 
dothelium is destroyed in limited layers of flat scales ; its place is sup- 
plied by small, round, newly-formed cells, which soon unite with the 
constantly-degenerating tissue of the synovial membrane, and cease 
to be distinguishable as separate layers. Through the progress of the 
plastic infiltration the synovial membrane gradually loses its former 
structure ; the connective tissue, filled with innumerable new cells, 
gradually becomes homogeneous, and from the constantly-increasing 
vascularization the tissue histologically exactly resembles that of gran- 
ulations. In these spongy granulations small white nodules form 
here and there ; these are sometimes like mucous tissue, some- 
times they are composed chiefly of pus-cells and even giant-cells. 
Anatomically there is no objection to calling these nodules "tuber- 
cles" (Koster), but we then run the risk of regarding them as the 
expression of the infectious disease now known as "tuberculosis." 
Similar changes take place on the surface of the cartilage, particularly 
at the points where it is covered by the fungous granulations. The 
cartilage-cells begin to divide up rapidly, while the hyaline intercel- 
lular substance melts, and is dissolved (Fig. 94) ; if from such a 
changed, perforated cartilage you cut a superficial piece parallel to 
the surface, around the defect you always find numerous cartilage- 
cells commencing to proliferate, and of course there is at the same 
time atrophy of the cartilage-tissue. At the points where the carti- 
lage is thus transformed to a non-vascular cellular tissue, it melts in 



508 



CHRONIC INFLAMMATION OF THE JOINTS. 



with the superjacent synovial proliferations ; the latter sinks loops of 
vessels into it, and the better the neoplasia is nourished by this 
means, the more rapidly it consumes the entire cartilage. From this 
description you see that the course of the dissolution of cartilage is 
about the same as in the case of bone, but with this important dif- 




Degeneration of the cartilage in fungous inflammation of the joint, a, Granulation-tissue on 
the surface, magnified 350 diameters ; after 0. Weber. 



ference, that the cartilage-cells themselves actively assist in dissolving 
the intercellular substance, while the bone-cells remain inactive, and 
absorption results solely from proliferation of the cells in the Haversian 
canals. But I must here state that in cartilage there are also occa- 
sionally appearances which show that sometimes the cartilage-cells 
do not take much active part, i. e., participate little in the cell-prolifera- 
tion, so that there may also be a more passive absorption of the car- 
tilage-substance from proliferation of the synovial membrane. The 
histological changes in the articular capsule and ligaments consist in 
serous and plastic infiltration which only attain a high grade at certain 
points, but generally only induce connective-tissue neoplasia), which 
to the naked eye resemble fatty thickenings. Since Cohn7iei?n , s 
observations have shown that a great part of the cells found in in- 
flamed tissues are wandering white blood-corpuscles, it seemed doubt- 
ful what part the cells of the stable tissues have in the inflammatory 
new formations. Although this question may not be answered for 
a time as regards the soft tissue, the new discoveries cause no 
change in the above observations, regarding the proliferation of carti- 
lage-cells by division. It is actually necessary to prove the latter 
over again by special new observations, because the surprising new 
facts regarding the former are so imposing, that one can scarcely 
believe his eyes. 



TUMOR ALBUS. 



509 



Now that you have a general view of the anatomical changes in 
fungous inflammation of the joints, we may go more minutely into 
the various modifications ; in so doing we shall start from the above- 
described course. So far I have represented the course of the dis- 
ease as it occurs when originating in the synovial membrane, but 
there are also other starting-points for the disease ; there may be a 
central, or more rarely a peripheral, caries in the spongy epiphysis of 
a hollow bone, or in one of the spongy bones of the wrist or ankle, 
and this may perforate from within outwardly through the cartilage, 
and thus excite synovitis. It also happens that, sometimes, along with 
the fungous proliferation of the synovial membrane, there is an inde- 
pendent proliferation under the cartilage, in the boundary between it 
and the bone (Fig. 93, g), which subsequently unites with that from 
above, so that the cartilage lies partly movable between the two 
granular layers. This occurs quite frequently, especially in the hip, 
elbow, and ankles. The cartilage is so loosened by this primary osti- 
tis of the ends of the bone or sub-chondral caries, that it may be re- 
moved apparently intact from the subjacent, vascular, soft bone. It 
has already been mentioned that inflammation of a joint may be in- 
duced by acute periostitis and osteomyelitis ; the inflammation then 
extends from the periosteum to the capsule of the joint, and thence to 
the synovial membrane; the anatomical changes are as above de- 
Fig. 95. 




Subchondral caries of the astragalus. Perforation of the proliferating granulations into the 
joint : magnified twenty diameters : a, cartilage ; b, granulations ; c, normal bone, with 
medulla. 



scribed. The infiltrations which we so often find around the sheaths 
of the tendons on the dorsum of the foot are often independent 
diseases of the cellular tissue of the periosteum and sheath of the 
tendon, but frequently they are due to ostitis of the ankle- 
bones. When an acute traumatic inflammation of a joint or an 
idiopathic acute suppurative synovitis passes into the chronic stage, 



510 CHRONIC INFLAMMATION OF THE JOINTS. 

the same anatomical changes go on as in fungous inflammation. 
Chronic periostitis in the vicinity of the joint may also cause inflam- 
mation of the joint, especially when it induces cold abscesses ; as may 
also chronic granular proliferations in the capsule, remains of neg- 
lected sprains of the joint. 

The external appearance especially is greatly influenced by the 
extent to which the parts immediately around the joint participate in 
the inflammation ; if the capsule participate very actively, the joint 
becomes regularly thick and round. This enlargement of the joint 
is also considerably increased by the formation of osteophytes, which 
form on the articular surfaces ; these will be the larger, the more the 
capsule and periosteum of the articular surfaces have been implicated, 
and the more proliferating and productive the disease generally; 
while from the joint the condyles and sesamoid bones are destroyed, 
from without new bone is formed as described to you under caries. 
Caries of the joint has an old .name, which is still occasionally used, 
it is arthrocace y this word is combined with the name of the different 
joints, tmd thus we speak of gonarthrocace, coxarthrocace, omar- 
throcace, etc. JRust wrote a book about diseases of the joint, and 
gave it the fearful name " arthrocacologie," which it is not worth 
your while to remember ; I only mention it as a curiosity ; it originated 
at a time when the study of eye-diseases also consisted almost exclu- 
sively in learning by heart the most frightful Greek names. The ex- 
tent to which the muscles suffer in tumor albus is important. In the 
vicinity of the inflamed joint, and often some distance from it, the 
contractile substance in the primitive filaments gradually disappears, 
usually after precedent fatty degeneration, and the affected limb 
atrophies more and more, in some patients more than in others ; the 
thinner it becomes, the more striking grows the enlargement of the 
joint, which often is not really very decided when you compare its 
measurement with that of the sound one. You will occasionally hear 
and read of the puffing up and enlargement of the articular ends of 
the bones in tumor albus ; this is a false expression ; in caries of the 
joint the bones never swell ; when they appear swollen, the swelling 
is due to the thickening of the soft parts or to formation of osteo- 
phytes. 

A further difference in the course of diseases of the joints lies in 
the greater or less tendency to suppuration ; abscesses and fistulae are 
by no means necessary sequelae of fungous inflammations of the 
joints, they are rather accidents. You already know that caries fun- 
gosa not unfrequently runs its course without suppuration. The fun- 
gous articular inflammations are often accompanied by caries sicca ; the 
affection may go on for years without the formation of abscesses, es- 



TUMOR ALBUS. 511 

pecially in adults otherwise healthy ; there may be extensive destruc- 
tion of the cartilages and bones, with the consecutive dislocations al- 
ready mentioned under caries, without a drop of pus. If, in such a 
case of so-called caries sicca, you examine the granulations in the 
joint and bone, you will find them firmer than usual, and occasionally 
of almost cartilaginous consistence, like granulations that are about 
to atrophy or cicatrize ; indeed, they do partly atrophy, but the pro- 
liferation often goes on again, and the bone is destroyed ; the pro- 
cess is thus analogous to cirrhosis. Hence suppuration is by no means 
a measure for the extension of the process in the bone ; on the con- 
trary, the more luxurious the proliferation of the granulations, the 
more extensive the destruction. The dislocation of the bones, the 
deformity of the joint, is the most important measure of the extent of 
the changes in the bones and ligaments ; if in a case of diseased knee 
the leg begins to rotate outwardly, and the tibia to shove backward, 
there is certainly destruction of part of the bone, and of a large part 
of the ligaments of the joint. In many cases fungous inflammation 
of the joint is accompanied by suppuration ; the pus is produced 
either by the granulations, or else forms on the surface of the syno- 
vial sac which is not much diseased; sometimes in the same sac 
there is a subacute synovitis, while another part of the sac remains 
intact, and still another is completely degenerated ; the knee and el- 
bow joints are especially liable to these circumscribed separate dis- 
eases of individual synovial sacs, which only communicate with the 
cavity of the joint by small openings. These suppurations are usu- 
ally accompanied by acute exacerbations of pain and fever, especially 
when the abscess opens externally, and synovial sacs, which have pre- 
viously participated little in the inflammation, suddenly become 
acutely or subacutely diseased. An early profuse suppuration of a 
joint is sometimes an evidence of the previously slight degeneration 
of the synovial membrane, as most pus is given out by serous mem- 
branes in the stage of purulent catarrh. The pus from the synovial 
granulations is usually of slight amount, and of serous or mucous con- 
sistence. The symptoms may be diiferent, if, as often happens, 
there be also suppuration in the cellular tissue around the joint, and 
periarticular abscesses (which, indeed, may occur without disease of 
the joints) accompany the fungous inflammation of the joints. All 
of these suppurations are important, from the fact that they impair the 
general health, partly by the loss of juices, partly by the fever. 

Lastly, we must give some attention to the vital condition of the 
inflammatory neoplasia. The vitality, the luxuriance of growth, and 
the future fate of the chronic inflammatory new formations, greatly de- 
pend, as you already know, on the general constitutional condition of 



512 



CHKONIC INFLAMMATION OF THE JOINTS. 



the patient ; in fact, this is so to such an extent that from the vital 
condition of the local affection we may often make a decision as to 
the general health of the patient. Fungous inflammation of the joint 
with caries sicca, and a disposition to cicatricial contraction of the 
new formation, usually occurs in persons otherwise healthy, and in 
these cases it is often difficult to find any cause for the chronicity of 
the disease, which was said to have been first induced by cold, fa- 
tigue, or injury of some sort. We also find the most luxuriant, 
spongy granulations and secretion of muco-pus in tolerably healthy, 
or at least well-nourished persons, in fat, scrofulous children, also as 
the chronic continuation of an acute articular inflammation in per- 
sons previously healthy, who have become anaemic from the long sup- 
puration. Great tendency of the neoplasia to break down into pus, 
or to molecular disintegration, is usually a sign of bad nutrition ; 
we find thin, badly-smelling pus in large amounts, with excessive ul- 
ceration of the skin, and fistulous openings, that look as if cut out 
with a punch, in the articular inflammation, with or without caries, 
of old cachectic patients, in badly-nourished tuberculous subjects and 
scrofulous children. Here we may have the same course of affairs as 
in torpid caries ; the neoplasm is very short lived, it breaks down al- 
most as soon as formed ; and along with the caries we have necrosis, 
as in the small bones of the wrist, more rarely in the epiphyses, also 
caseous degeneration of the neoplasm. 

Fig. 96. 







^ 



w /■ 



Atonic ulceration of the cartilage from the knee-joint of a child; the cartilage-cells, which only 
proliferate slightly, undergo fatty degeneration, and they, with the intercellular substance, 
break down very rapidly. Magnified 250 diameters. 



We could distinctly separate this atonic form of chronic suppura- 
tive inflammation of the joint from the fungous variety, but avoid 
doing so : first, that we may not disturb the general description ; sec- 
ondly, because this form also often begins as a typical fungous syno- 
vitis, and subsequently passes into the torpid form as the nutritive 
state of the patient declines. We find it chiefly on autopsy, and 
should altogether mistake the earlier stages if we did not study the 
disease in resected and amputated joints. I shall not continue the 
anatomical details, which might be carried much further, but what has 



TUMOR ALBUS. 513 

already been said will suffice to explain to you any given case. It is 
not impossible to group the different modifications of the above pro- 
cesses in classes and to analyze them separately ; but this seems to 
me of no practical value, for these forms offer at present no special 
etiological, prognostic, or therapeutic features. If you correctly un- 
derstand the anatomical course and recall my description in all cases 
that you see living or dead, in resected or amputated limbs, you will 
soon understand the disease and require no further classification of 
its symptoms. 

About the causes of chronic fungous articular inflammation there 
is little to say beyond what you already know. The scrofulous diath- 
esis especially predisposes to it ; acute, spontaneous, or traumatic 
(whether from wounds, contusions, or sprains) inflammations of the 
joint occasionally become chronic. Scrofulous children, three years 
old and upward, are especially inclined to these joint-diseases ; a fall 
or twisting of the joint often proves an exciting cause. Cases occur 
where we can find no local or general cause for the disease. In Swit- 
zerland I have very often seen atonic forms of fungous purulent in- 
flammations of the joint in old people, where no cause for them could 
be discovered. 

The course of this disease is very varied, but it is always chronic, 
lasting for months, usually for years; often interrupted by pauses 
and improvement, then again exacerbating. The disease may halt, 
and recover at any stage ; in the first stages this recovery may be per- 
fect, that is, the joint may remain entirely movable ; or it may be im- 
perfect, that is, more or less stiffness of the joint is left. Before the 
cartilage has commenced to proliferate, or has its under surface dis- 
turbed by any neoplastic tissue growing from the bone, there is a 
possibility of tolerably good motion being restored — which, however, 
may be impaired by cicatricial contraction of the fungous synovial 
membrane, and of the infiltrated ligaments, as well as by secondary 
contractions of the muscles. If the cartilage be partly or entirely 
destroyed, and caries has occurred gradually or with the onset of the 
disease, it may recover with anchylosis, the cartilage is not restored ; 
the granulations of the adjacent surfaces of cartilage gradually unite, 
and often firm adhesions form, which may even ossify. Whether the 
disease goes on so far or the destruction of the joint continues to 
progress, depends greatly on the constitution of the patient ; treatment 
may be of great benefit, if begun early. The extent to which the 
muscles sympathize varies greatly ; according to my experience, the 
highest grade of muscular atrophy occurs in those cases where there 
is no suppuration of the joints but caries sicca, and where the joint- 
disease seems to proceed from ostitis. 
33 



514 CHRONIC INFLAMMATION OF THE JOINTS. 

Now for a short discussion of certain symptoms. Each form of this 
disease may run its course with more or less pain ; the cause of this 
I am unable to explain ; there are cases where the bone is extensively 
destroyed, without any pain, others where it is very severe ; the acute 
exacerbations with development of new abscesses are always rather 
painful — on probing the fistulas we sometimes find bone, at other 
times not ; whether we feel it or not, depends on whether it is covered 
with granulations or lies exposed ; the same is true of friction ; crep- 
itation is only valuable as a sign of caries of the articular extremi- 
ties, when it exists ; if it fail in the later stages, it is no proof that 
the bone is not diseased. The deformity, the displacement of the 
articular surfaces, pathological or spontaneous luxations, are the only 
evidence at all certain of the extent of the destruction of the bone ; 
here we can only be deceived when the capsule has ruptured early, 
and the head of the bone is actually luxated ; a rare case, w T hich has, 
however, been seen in the hip, and might possibly occur in the shoulder. 
In regard to judging of the anatomical condition of the joint, little can 
be added to what has already been said, but we have some assistance 
from the etiology and duration of the complaint. Profuse suppuration 
from the joint is always a sign that part of the synovial membrane 
has not yet been destroyed, or that there are large abscesses near the 
joint ; the secretion from fungous granulations is less abundant, serous 
or mucous. We have no certain evidences of the extent to which the 
cartilage is destroyed. To add any thing about the diagnosis and 
prognosis would only be to repeat what has already been said, from 
which you have all the data for forming your judgment. From my 
own experience, I think I may say that slight swelling of the joint, 
with great pain and early muscular atrophy in anaemic children, but 
with little or no suppuration, indicates primary disease of the bone, 
and renders the prognosis very bad. A good nutritive condition is 
the most important point for a favorable prognosis, which would not 
be very greatly affected even by early and extensive suppuration. 



LECTURE XXXVIII. 

Treatment of Tumor Albus.— Operations.— Eesection of the Joints.— Criticisms on the 
Operations on the Different Joints. 

Now let us take up the subject of treatment. As in all chronic 
inflammations, this must be both general and local, and the general 
treatment should be the more prominent, the more chronic and insid- 



TREATMENT. 51 5 

ious the disease ; it is unnecessary for us to waste words over this 
constitutional treatment, which will depend on the peculiarities of 
each case; you already know its outlines. The salient points for 
treatment are, the nutritive state of the patient, the quality of his 
blood, and the general hygienic and dietetic conditions under which 
he lives. It is your duty conscientiously to advise your patient to 
the best of your knowledge, but you will soon find that on these 
points you meet the greatest indifference, and that your advice will 
rarely be followed. The worst instances, such as hereditary predis- 
position, we shall not be able to affect ; for we can never expect tc 
choose the strongest persons out of healthy families for the propaga- 
tion of the species, and to forbid marriage to feeble persons from 
sickly families. Regarding the local treatment and its results, we 
may say, in general terms, that it is the more effective the more acute 
the stage ; as a rule, it is not difficult to relieve subacute exacer- 
bations, or subacute commencements of the disease. In these 
cases we derive great benefit from the already oft-mentioned reme- 
dies : strong salve of nitrate of silver ( 3 j to § j of lard), paint- 
ing with tincture of iodine, flying blisters, wet compresses, gentle 
compression with adhesive plaster; this should be accompanied 
by absolute rest of the joint, which in the lower extremities can only 
be attained by continued confinement to bed. 26 If the course of the 
disease is entirely chronic, and does not improve after a trial of rest, 
and the remedies above mentioned, I know of no better treatment 
than the maintenance of continued moderate pressure on the swollen 
limb by means of a firm bandage, such as a plaster-splint, which at 
the same time keeps the joint perfectly quiet in a suitable position. 
With such a dressing we may permit the patient to go about, if it 
does not pain him ; in so doing, he may use a cane or crutches, ac- 
cording to the weakness of the affected limb. Should the patient 
need baths at the same time, the bandage may be divided longitu- 
dinally, and be removed before the bath and replaced subsequently. 27 
This treatment has the advantage that the patient uses the muscles 
of the extremity somewhat at least, and consequently they do not 
entirely atrophy ; we are not to think that stiffness of the joint must 
necessarily result from wearing the plaster-splint for a length of time ; 
we not unfrequently find the opposite, that is, that a limb which was 
very slightly movable before the application of the dressing is more 
so afterward ; this is because the swelling of the synovial membrane 
often subsides under the bandage. Before applying the plaster-dress- 
ing we may rub the limb with mercurial ointment, or apply mercurial 
plaster, or even rub in the nitrate-of-silver ointment. In all chronic 
cases of fungous inflammation of the joint, I cannot sufficiently recom- 



516 CHRONIC INFLAMMATION OF THE JOINTS. 

mend to you the plaster-splint ; this treatment appears very inefficient, 
yet it is more useful than all the other remedies that we have for 
combating this disease. I can assure you that, since following this 
treatment perseveringly, my cases are less frequently complicated 
with suppuration and fistulas. Even when there is evident fluctuation 
you may apply the dressing ; it is true you will rarely see the abscess 
reabsorbed, still, when it opens spontaneously under the bandage, as 
the patient will readily notice from the moistening of the dressing, 
this will take place more quietly, propitiously, and painlessly, than 
under any other plan of treatment. When fistulas have formed, we 
may still use the plaster-splint, simply slitting it up and putting in new 
wadding ; it should be removed daily and the sores dressed, then re- 
applied; at the same time the constitutional treatment should be 
persevered in. If the limb be very painful, and there are any fistu- 
las present, we should use splints with openings. In this way I have 
occasionally preserved a good, useful position in joints moderately 
movable, wiiere the prognosis was at first very bad, and have indeed 
been frequently most agreeably surprised at the results of this treat- 
ment. Extension must be undertaken very carefully in joints that 
are suppurating or much diseased in any way, and, if even during 
anassthesia there should be resistance, complete extension should 
never be made at one sitting, but it should only be carried so far as 
may be done without great force. In knee and hip diseases I use, 
with great benefit, the extension by weights which has been so often 
recommended, and occasionally thus prepare patients, especially chil- 
dren, for the application of the plaster-bandage. Vblkmann deserves 
many thanks for his energetic recommendation of this plan of treat- 
ment, which he calls the " Distractionsmethode." He attaches great 
importance to the fact that the extension reduces to a minimum the 
pressure of the articular surfaces on each other, that is caused by the 
tension of the muscles and contraction of the ligaments. The mode 
of applying the extension is so very important for the practical use of 
this method, that I must particularly recommend you to give your 
special attention to its mechanical application in the clinic. 28 

Perseverance on your part and on that of the patient is absolutely 
necessary, for the cure of chronic inflammations of the joints ; repre- 
sent to the patient, at the outset, that this is a disease of at least sev- 
eral months', possibly of some years' duration, and that the dressing 
is not to be left off till the limb is free from pain, and strong enough 
to walk on, whether motion be lost or not. Regarding cold abscesses, 
I repeat the advice only to open them, when you propose to follow 
them at some time by an operation ; if this cannot be done, or you do 
not intend to do it, leave the opening to Nature, even if it should re- 
auire vears. 



TREATMENT. 5 If 

So far, I have briefly given you my maxims regarding the tieat- 
ment of fungous inflammation of the joint, but I must not neglect to 
call your attention to the fact that other surgeons have different views 
on the subject. There are still advocates of the strong classical anti- 
phlogistic treatment, who, even in chronic inflammations of the joints, 
from time to time apply leeches or wet cups, put on compresses with 
lead-water, and give cathartics ; later they use cataplasms, and finally 
moxa3 and the hot iron. If the disease continues to advance, if fis- 
tulae have formed here and there, if the patient has become very 
anaemic, they consider amputation indicated, especially when there is 
crepitation in the joint. This was the old belief; the results were gen- 
erally unfavorable or favorable, as we may choose to consider them ; 
that is, they were the latter so far as regards the favorable course of 
the amputation, which was made, sooner or later, under such circum- 
stances. Even now it astonishes me to see how often amputations of 
the thigh are made for tumor albus of the knee, in many hospitals ; it 
is. not saying much to mention that, in my own hospital service, I 
have rarely found thigh-amputations indicated for caries of the knee ; 
but it appeared to me very remarkable that, during the seven years 
[ was assistant in the surgical clinic at the University of Berlin, there 
were only two amputations of the thigh for caries of the knee, while 
formerly, in the reports of the smallest hospitals, several such ampu- 
tations were reported every year. I am much inclined to refer the 
more favorable results, the rarer indications for amputation, to the 
treatment of the disease by the plaster-bandage, which was chiefly in- 
troduced and persistently carried out by Von Langenbeck ; and I am 
firmly convinced that, by it, a large number of limbs have been 
preserved in a relatively good condition, which, in former times, would 
certainly have been amputated. I would not recommend the abstrac- 
tion of blood in chronic disease of the joints ; it can only prove bene- 
ficial in subacute exacerbations, and in these very cases we have 
better remedies, which are not at the same time injurious ; for it is 
certainty improper to abstract blood once, or even oftener, from pa- 
tients who are inclined to anaemia by their disease itself. In some 
cases of subacute attacks in chronic inflammation of the joints, cold 
is an excellent application ; in such cases I now use ice with good re- 
sults ; but I cannot say that cold would be particularly beneficial in 
cases that run their course without outward symptoms of inflamma- 
tion ; and it is no slight affair to treat a patient with ice for years, 
keeping him in the same position in bed with a bladder of ice on his 
knee, which, at any rate, does not give him much pain. JEsmarch 
claims very favorable results for persevering treatment with ice. Now 
I must speak of the persistent application of heat, which may be ac- 



518 CHRONIC INFLAMMATION OF THE JOINTS. 

complished by the careful application of cataplasms, compresses wet 
with warm water, or even the continued use of warm baths for weeks. 
This treatment may be indicated when the course of the disease is ex- 
ceedingly torpid, when bad-looking fistulous ulcers, deficient vascularity 
of the granulations, or bad, thin secretion, seems to indicate a moder- 
ate irritation of some kind. However, when high temperatures are 
applied, they should not act too long, or their effect will be lost, and 
there will be complete relaxation of the parts, instead of the fluxion 
that it was proposed to excite. 

From the above description of the benefits of treatment, you may 
see that in fungous inflammations of the joints the results are gener- 
ally good, if we leave out of consideration the greater or less stiff- 
ness of the joint which remains ; this is particularly the case if the 
patient is treated early. Still, some cases are not cured, in spite of 
the most careful treatment ; this is partly due to the anatomical con- 
dition of the joint, partly to the general health of the patient. For 
anatomical reasons, disease of the joints of the hands or feet is the 
most unfavorable ; from the many small bones and joints affected, the 
progress is usually excessively tedious ; the disease may begin quite 
chronic at one of the small joints of the hand or foot, may remain 
stationary at this point for a time, then spread to the next two, again 
halt a while, or even recede ; but a new joint is attacked ; suppura- 
tion begins first in one place, then in another, the patient grows 
anasmic and weak, he is condemned to inaction for years, and finally 
longs to have the affected limb amputated, so that he may once again 
feel well, after his years of suffering. In other cases a scrofulous or 
tuberculous cachexia gradually induces anaemia, indigestion, fatty de- 
generation of the internal organs, tuberculosis of the lungs, etc., so 
that from the general health of the patient we must give up all hopes 
of a cure. If, under such circumstances, we leave the disease to itself, 
the patients die after years of suffering ; the end comes the sooner the 
larger the joint affected (knee, hip), and the greater the number simul- 
taneously affected, as is apt to be the case in scrofula and tuberculosis. 
Under such circumstances we may resort to two modes of treatment : 
1. Give up the limb to save the life, that is, amputate ; 2. Give up the 
attempt to cure the joint-affection, cut out the diseased ends of bone, 
so as to save both life and limb, that is, resect the joint. 

Comparing these two remedies theoretically, there can be no doubt 
that resection is preferable to amputation, and in principle this is cer- 
tainly true ; modern surgery is justly proud of the institution of re- 
section of joints. Nevertheless, certain circumstances may combine 
to render amputation preferable in any given case ; chief among these 



TREATMENT. 519 

Is the state of the patient's general health. After resection of the 
joint we have left a large wound with two sawed edges of bone, 
which will certainly continue to suppurate for weeks, possibly for 
months ; there may be suppuration of the subcutaneous tissue, of the 
sheaths of the tendons, and suppurative periostitis and necrosis of the 
sawed edges, things which patients may live through, but which al- 
ways require time and strength. If, then, in badly-nourished, cachec- 
tic persons, loss of strength should indicate operative interference, 
amputation is often a more certain remedy for saving life than resec- 
tion. The surgeon should always think more of saving the life than 
the limb. We have also to answer the question, Can the patient 
bear resection, with its sequelae ? It is difficult to give a general an- 
swer to this question ; even in individual cases a decision may be diffi- 
cult : we must determine whether the patient is emaciated, anaemic, 
and debilitated, simply by the drain on his system, or if there be more 
serious lesions of internal organs ; in the latter case amputation would 
be preferable, if, indeed, any operation would be serviceable. Of 
aourse we do not operate on atrophic children with disease of several 
joints, cold abscesses," diarrhoea, aphthae, etc., or on persons with 
tuberculous cavities in the lungs, or with indurated, fatty liver and 
spleen, or on old marasmic individuals ; we cannot give any aid to 
such patients. But a still more important question is, Which opera- 
tion is less dangerous to life ? We cannot give a general answer to 
this question ; we must separately consider the joints concerning 
which the question of resection arises. In caries of the s7ioulder-]omt 
resection is less dangerous than disarticulation of the arm at the 
shoulder-joint ; the same is true of the hip-joint y hip-joint amputa- 
tions are among the most dangerous in surgery, while in young sub- 
jects resection is not so very fatal. Hence we are not to think of 
exarticulation at the shoulder or hip on account of caries ; here the 
only question is, Is the general health of the patient such that we 
should let the disease run its course, or shall we arrest it by resection ? 
In the most favorable cases of spontaneous cure there will be anchy- 
losis in a bad position ; if recovery takes place after resection, the 
extremity remains movable at the shoulder or hip joint. These chances 
speak strongly for resection, especially at the shoulder-joint ; here we 
might decide on resection quite early, even in order to get the patient 
about soon and in good order. Resection of the hip is open to one 
grave objection : we cannot resect the acetabulum, which is usually 
diseased at the same time, or we can only do so imperfectly ; hence, 
when the joint is much diseased, the resection is imperfect ; slighter 
grades of the affection may even recover without operation. 

In the elbow-joint the state of affairs is more favorable, perhaps the 



520 CHRONIC INFLAMMATION OF THE JOINTS. 

most favorable ; the resection of this joint is not more dangerous than 
amputation of the arm ; but, in favorable cases, after resection, quite 
a useful joint is left, while after spontaneous recovery there is gen- 
erally anchylosis ; in these cases the choice is easier : we prefer re- 
section of the elbow-joint, not because the operation must be done to 
save life, for caries of this joint is only dangerous from long duration, 
but because, while the danger is relatively slight, it offers good chances 
of motion, and in any other case there is usually anchylosis ; indeed, 
the anchylosed joint has even been sawed out in order to obtain a 
movable false joint. Unfortunately, more recent observations on the 
motility of arms with resected joints have shown that the false joints 
formed after operation become more relaxed in the course of years, so 
that finally the operated extremity does not remain as useful as was 
formerly supposed. The case is very different with the knee-joint; 
here resection is quite a dangerous operation, being on a par with 
high amputations of the thigh ; after resection of the knee we only 
obtain anchylosis, which is also the result of spontaneous recovery. 
Now, as this operation is quite dangerous, and as it gives no better 
results than non-operative treatment, in case the disease is arrested, it 
should only be done to save life, and, even in this respect, it is of 
doubtful advantage. I have rarely decided on an operation for caries 
of the knee-joint, either for amputation or resection ; we can only pro- 
pose amputation when all treatment is fruitless, and the patient is 
failing rapidly, or when it is an old person in whom extensive caries 
of the joint would be very unlikely to heal. 

The above are my personal opinions, which constantly become 
more fixed, as I see more such knee-diseases recover spontaneously. 
I have seen many children die of coxitis, and consequently am rather 
in favor of resection of the hip, in spite of the want of success of my 
own operations ; the only deaths I have seen from caries of the knee 
have been in old, marasmic persons and those with tubercles and ex- 
tensive cavities in the lungs, while they have been rare in children ; 
in all of these cases operation would have been useless. Here you 
have my belief about operations of caries of the knee. Other surgeons 
have different opinions ; in England, especially, the operation is so 
popular that it is very often performed. I believe that many German 
surgeons share my views on this subject, others are more undecided, 
as they view this operation more favorably from having seen a few 
successful resections of the knee-joint. Formerly, I was entirely op- 
posed to resection of the knee-joint, but have been rather unsettled 
by a series of favorable results that I have lately had from this oper- 
ation. If the cases with good chances be chosen for operation, and 
unfavorable or doubtful ones never operated on, the operations will be 



TREATMENT. 521 

mostly successful, but few patients will be cured, The same is true 
of most great operations ; if one has some experience, and does not 
hesitate to send most cases away uncured, interesting himself only 
in the favorable cases, he may soon attain the reputation of a very 
fortunate operator. Many eminent surgeons deceive themselves in 
this way. 

Now we come to the wrist-joint ; here resection usually consists in 
the removal of all the bones, and sawing off the low T er surfaces of the 
radius, perhaps also those of the ossa metacarpi. I have performed 
this operation several times, occasionally with brilliant results, the hand 
becoming perfectly movable and the fingers useful ; two of the pa- 
tients were seamstresses, and were able to resume their occupation, 
the third and fourth unfortunately lost patience ; after the operation, 
when the wound had closed except two fistulas, and the pain had 
ceased, they stopped treatment ; there were still some carious spots 
in the metacarpal bones which should have been extirpated, when the 
result would certainly have been as good as it was in the previous 
cases. I should have liked to resect the hand more frequently, but 
several times have submitted to the patient's special request to am- 
putate the forearm. It must seem strange that a patient does not 
readily consent, when the surgeon proposes, by a tolerably safe opera- 
tion, such as resection of the wrist, to preserve the hand ; I always 
felt obliged to say that it would be several months before the wound 
healed, so that the patients should not expect too much ; they replied 
that it was too long a time, they had not used the hand for four, five, 
and eight years, and it always pained them ; they were tired of treat- 
ment, and had decided to lose the hand, so they would not again un- 
dertake a long course of treatment. I have told you this that you 
may see what obstacles the surgeon runs against when he honestly 
tries to do the best. All the cases of caries of the wrist are by no 
means suited for resection ; we never decide on an operation before 
there is extensive destruction of the bones, although we know that 
caries of the wrist very rarely spontaneously recovers with movable 
joint. Caries of the wrist is not frequent as compared with that of 
the knee and hip, and is particularly rare in children, being more fre- 
quent in adults. The cause of the difficulty of recovery is partly due 
to local conditions which we have previously described. Besides this, 
there are about the hand so many tendons, most of whose sheaths par- 
ticipate in the disease ; the fingers are stiffly extended, the metacarpal 
bones, radius, and ulna, are also frequently diseased, though they may 
be only affected with periostitis. The other soft parts about the 
hand, especially the skin, are perforated by numerous fistula?, or even 
extensively destroyed, so that the most favorable circumstances for 



522 CHRONIC INFLAMMATION OF THE JOINTS. 

resection do not exist. Hence, where extensive caries of the hand is 
accompanied by considerable degeneration of the neighboring parts, 
amputation of the forearm will justly assume its old position. Ex- 
traction of single metacarpal bones, or simply sawing off the radius, is 
rarely sufficient; I have, indeed, seen cases where the disease was 
limited to one or two metacarpal bones ; these had become necrosed, 
and the disease terminated at that point ; the patient was sent to me 
for amputation of the hand, and was much pleased when, after exam- 
ination, I told him that amputation was not necessary. But these 
cases are rare ; usually the disease advances, and is not arrested by 
the extirpation of the bones which are chiefly diseased. I think that, 
on the whole, total resection of the wrist is still too little employed ; ac- 
cording to my experience, it is worthy of the greatest attention from 
surgeons. This operation, as well as a similar one on the foot, of which 
we shall speak shortly, is well supported by a reasoning that has been 
falsely applied to resections in general; i. e., if resection does not 
arrest the local disease, we may still amputate. In resections of the 
hand and foot this is true, and they are rarely followed by pyaemia, 
but the case is not the same with the shoulder, hip, elbow, and knee. 
If these operations are unsuccessful, if suppuration be exhausting, or 
pyaemia occur, we can hope little from amputation or exarticulation. 
Lastly, we come to the ankle-joint, comprising the joints of the tarsus 
as well as the tibio-tarsal articulation. The circumstances here very 
closely resemble those for the wrist ; although caries of single bones, 
as the not unfrequent caries necrotica of the calcaneus, will spontane- 
ously recover with time, especially in children, just as scrofulous caries 
of the fingers, toes, metatarsal and metacarpal bones do, even in young 
adults, caries of the joints of the foot rarely recover spontaneously, 
and in old persons hardly ever do so. Consequently, in these cases 
operation will frequently be indicated at some stage of the disease, 
and on superficial observation we might think that resection and ex- 
tirpation of bone should be very commonly resorted to ; but, practi- 
cally, there are two objections to the extensive resort to these 
operations in caries of the foot : 1. The experience that, after extirpa- 
tion of one bone, the disease often attacks another, and consequently 
perfect recovery does not result. 2. The fact that the foot must 
always retain sufficient firmness for the patient to walk ; so, while we 
may remove the cuneiform bones, the scaphoid and cuboid, or even 
the astragalus or calcaneus, if we remove both the latter bones, and 
perhaps also saw off the articulating surfaces of the tibia, we should 
have a rather useless foot, which would be worse than a good stump. 
The cicatrices occurring at the place whence the bone was extirpated 
contract greatly after a time, and even if some bone form in this cica- 



TREATMENT. 523 

trix, still it is not regenerated as after necrosis, but the foot contracts 
greatly at the point from which the bone is absent, and thus becomes 
distorted and useless. These are decided objections; moreover, a 
good stump, such as is left by Chopar€s or Pirogoifs operation, is 
often just as good or even better for walking than a weak, deformed 
foot, and it requires several months to get the latter into shape, 
while the former may be obtained in six to eight weeks. In one case, 
I removed all three cuneiform bones, and the os cuboid, with good 
results ; in other cases, in boys, I have removed the astragalus ; then 
the tibia articulated with the calcaneus, the new joint remained mova- 
ble, and the patient did not even limp ; such results are very encour- 
aging for this operation. Another time I wished to remove the cal- 
caneous alone for caries, but unexpectedly found the lower part of the 
astragalus affected, and had to remove it also ; the result was miser- 
able: the young boy lay six months in the ward, and even then did 
not recover, so I amputated at the lower part of the leg, and the 
wound healed by first intention ; a few weeks later, the patient left 
the hospital well, with a good wooden leg, glad to be rid of his sore 
foot. The very favorable results of Pirogoff's amputation make a 
strong opposition to resection of the ankle-joint, and I think that 
experience will soon speak more strongly than now against too great 
employment of exsection, and for amputations through the foot. 

Resections of joints, which have excited so much controversy the 
last twenty years, at first appeared so brilliant from the favorable 
results in certain joints, such as the elbow and shoulder, that they 
were sometimes too much resorted to ; this is the fate of all inventions 
of the human mind. We are only now gradually coming to certain 
indications for these operations ; of course statistics had first to be 
collected, and it was soon found that resection was of varied value in 
different joints. Although I am not prepared to say that the question 
is even now settled, still I believe I have given you a correct resum& 
of the present position of affairs. 29 

I cannot refrain from making one observation at the close of this 
chapter. In the Canton Zurich patients who had been successfully 
treated for caries, by resection or amputation, often returned, and, 
sad to say, many of them who, after suffering for years, had been per- 
fectly cured, and had left the hospital quite strong, came back after a 
year or two with caries of other bones, or with tubercles of the lungs, 
and often died there. I have been unable to gather any extensive 
statistics as to the final terminations of bone and joint diseases, but 
fear that they will prove much more unfavorable than we generally 
incline to believe. 30 



524 CHRONIC INFLAMMATION OF THE JOINTS. 



LECTURE XXXIX. 

i?.— Chronic Serous Synovitis. — Hydrops Articulorum Chronicus : Anatomy, Symp- 
toms, Treatment. — Typical Recurrent Dropsy of the Knee-Joint. — Appendix: 
Chronic Dropsies of the Sheaths of the Tendons, Synovial Hernias of the Joints 
and Subcutaneous Mucous Bursas. 

#— CHRONIC SEROUS SYNOVITIS.— HYDROPS ARTICULORUM CHRONI- 
CUS.— HYDRARTHRUS. 

The chronic diseases of the joints that we have now to describe 
are much more rare than fungous synovitis and its results, which we 
have already described; taken altogether, they are scarcely so fre- 
quent as the former, and, as a body, they form a decided contrast to 
suppurating inflammations of the joints, for they never spontaneously 
suppurate, they only do so when acted on by repeated irritations, in- 
juries, etc. 31 We shall commence with the most simple of these forms, 
with chronic serous synovitis, or hydrops articulorum chronicus, or 
hydrarthrus. The disease consists in a morbid, slowly-increasing 
collection of rather thin synovia; the synovial membrane changes 
very little, it gradually becomes somewhat thicker and firmer, the 
connective tissue increases, but without any marked increase of vas- 
cularity ; the tufts elongate, and, although the vessels form into loops 
at their apices, the substance retains the firmness of connective tissue, 
while from plastic and serous infiltration it grows soft and resembles 
granulations in fungous synovitis. In serous synovitis this does not 
occur ; the entire pathological changes of tissue are very slight, even 
when the disease has lasted a long while. Some surgeons wish to 
consider these dropsies of the joints, as well as similar diseases of the 
mucous bursas, as not belonging to the chronic inflammations, but as 
constituting peculiar diseases. This does not seem to me justifiable. 
No one will dispute that chronic catarrhs of the mucous membranes, 
with a tendency to hypersecretion, are to be classed among the chronic 
inflammations ; chronic dropsy of the synovial membrane is perfectly 
analogous to chronic catarrh of the mucous membranes. 

Chronic dropsy of the joints is often the remains of an acute artic- 
ular dropsy, caused by contusions, catching cold, etc., as has already 
been described ; but in many cases, also, the disease is chronic from 
the start, and remains so. Hydrarthrus is most common in young 
men, and occurs most frequently in the knee-joint ; it often comes on 
both sides ; it is very rare in the shoulder, hip, or elbow ; I have never 
seen a pure case of it in the other joints. When the disease is well 
advanced it is readily recognized, and even the laity know it as 
" dropsy of the joint." The joint is much swollen, fluctuates all 



CHROXIC SEROUS SYNOVITIS. 525 

over ; in the knee we have also the motion of the patella ; it is lifted 
up by the fluid, and may be readily pressed again into the intercon- 
dyloid fossa, occasionally with a perceptible sound. As the surfaces 
of the joint are united by firm ligaments (in the knee by the lateral 
and crucial ligaments), which are not so easily stretched, the fluid 
collects chiefly in the mucous bursas adjacent to the joint, and on this 
account we may often diagnose the swelling as synovitis by simple 
inspection, especially in the knee-joint, where the bursas under the 
tendons of the extensors at both sides of the patella, and in the 
popliteal space, are greatly distended by the fluid; while, on the 
other hand, in regular swelling of the capsule, the enlargement is 
regularly round. Sometimes, also, patients with this disease can 
move their joints quite freely and without pain ; they can often walk 
quite a distance, and occasionally have so little inconvenience that 
they do not ask advice of the physician ; even examination of the 
joint by palpation is painless. Where the dropsy of the joint is 
considerable, great exertion readily causes fatigue of the limb, as well 
as pain and increased exudation ; however, after resting a while, this 
passes off, and generally the inconvenience is very slight. 

The prognosis is good in so far as these dropsies of the joint lead 
to nothing further; the fluid may increase enormously, but that is all; 
unless there be some overstraining or injury, the disease remains the 
same. As regards recovery, the prognosis is most favorable in those 
cases where the disease remains after an acute or subacute commence- 
ment; in these cases, as a rule, complete recovery takes place by 
reabsorption, although it may be slow. On the .other hand, those 
cases where the disease is chronic in its commencement and course 
are very obstinate, and are often extremely difficult to cure. 

The treatment consists in the application of the remedies already 
described, which are to be perseveringly used while the joint is kept 
at perfect rest, viz., tincture of iodine, flying blisters, and compres- 
sion. The latter is the most effective remedy, but it must be strong 
and continued (forced compression, according to Vblkmami) ; we may 
apply firm dressings with moist or elastic bandages ; the patient must 
lie still during the treatment ; if there should be any oedema of the 
leg, it will do no harm, but, if the toes grow blue and cold, the band- 
age must be removed. If the patients will not submit to this treat- 
ment, we may let them wear a large mercurial plaster, with a snugly- 
fitting knee-cap of leather with elastic insertions, which prevents too 
much motion of the joint, and gives the limb more firmness and se- 
curity in walking. If all this treatment does no good after months 
or years, or if the improvement has only been temporary, we may still 
resort to simple tapping, or to tapping, followed by injection of iodine. 



526 CHRONIC INFLAMMATION OF THE JOINTS. 

Usually simple tapping does little good. You pass a fine trocar into 
the joint alongside of the patella, allow the fluid to flow out slowly, 
and close the canula a little before it has all escaped, so that no air 
may enter the joint, then cover the wound with adhesive plaster; 
now paint the joint with tincture of iodine and envelop it with wet 
bandages or a collodial bandage, and in some cases you may attain a 
cure ; there will be a rapid collection of serum and some pain in the 
joint ; this new fluid may be completely absorbed. If this operation 
has done no good, if the fluid collects again to the same amount, and 
remains unchanged, you may make the tapping followed by injection 
of iodine. This operation is not free from danger ; you perform it as 
follows : First tap the joint carefully, as above directed, then fill a 
well-made syringe with a mixture of officinal tincture of iodine and 
distilled water in equal parts, or, if you wish to be very careful, one 
part of tincture of iodine to two of water ; after seeing that there is 
no air left in the syringe, you may inject from one to two ounces of 
this mixture, according to the amount of previous distention of the 
joint ; keep the fluid in the joint three to five minutes, according to 
the pain induced, then let it escape slowly ; now carefully close the 
wound, and make compression, as above described. A new acute 
serous exudation always results ; this remains stationary about eight 
days, and is then slowly absorbed, and recovery usually follows. Of 
course, under such treatment, as after simple tapping, the patient 
must remain absolutely quiet, for there is always inflammation, and 
perfect rest is the first requirement in inflamed joints. It is not quite 
evident why it happens that, when tincture of iodine comes in contact 
with a serous membrane which was disposed to excessive secretion, 
even for a short time, it should have such an influence in altering and 
arresting the secretion; formerly it was thought that after these in- 
jections, which were advantageously used in many chronic dropsies 
of serous membranes, there was adhesive inflammation, a union of 
the surfaces of the serous sac, and its consequent obliteration ; this is 
by no means the case, at least after the successful injections of iodine 
in hydrops articuli ; if such adhesions occurred here, the joint would 
become stiff. What really occurs is as follows : The iodine is de- 
posited in the surface of the membrane and in the endothelium ; it 
remains here for months, at least, and by its presence appears to pre- 
vent further secretion. At first there is strong fluxion with serous 
exudation (acute serous synovitis), but the serum is again absorbed 
by the still-distended vessels, and subsequently the membrane shrinks 
to the normal volume by condensation of the connective tissue, which 
subsequently remains more dense. So we may consider the process 
of cure as analogous to the similar process in the tunica vaginalis 






CHRONIC SEROUS SYNOVITIS. 527 

propria testis, in the cure of hydrocele of the tunica vaginalis, or 
water-rupture ; after injections of iodine in hydrocele, there has been 
an opportunity of making many examinations, from which the course 
of the cure appears to be as above stated ; the shrinkage of the serous 
membrane, with new formation of endothelium, seems to me to be the 
final cause of the arrest of the secretion. 

Iodine injections in hydrarthrus are made by few surgeons ; I have 
seen them made three times, and have made two, always with good 
result ; but this is not always the case ; then they must be repeated, 
but I warn you against repeating them too soon : you should at all 
events first allow the acute stage after the operation to subside. 
Cases have also occurred where severe inflammations of the joint have 
resulted after these iodine injections, which have been most used in 
France because they are a French invention (of JBoinet and Velpeau) ; 
as so often happens in traumatic articular inflammations, the acute 
serous synovitis became purulent; in favorable cases there was re- 
covery with anchylosis, in some cases amputation was necessary, in 
other cases the patients died of pyaemia. These unfortunate termina- 
tions of an operation done for a disease, which is obstinate it is true, 
but not dangerous to life, have justly rendered injection of iodine into 
the joints unpopular ; it is always dangerous to the joint and to life, 
and hence should be done as rarely as possible. 

The diagnosis of hydrarthrus is usually simple, and the disease 
always very different from chronic fungous purulent synovitis ; how- 
ever, I would caution you that, in the commencement of tumor albus, 
also, there is occasionally a slight amount of serous exudation, and 
even fluctuation, in the joint, so that at first the diagnosis cannot always 
be exactly made ; but observation for a few weeks suffices to show the 
nature of the disease, and, moreover, hydrops articulorum occurs chiefly 
in young adults, while tumOr albus is most frequent in children. 



APPENDIX. 



CHRONIC DROPSIES OF THE SHEATHS OF THE TENDONS, MUCOUS BURS^E, 
AND SYNOVIAL HERNIAS. 

We shall now say something of the chronic dropsies of the sheaths 
of the tendons. The disease consists in an abnormal increase of the 
synovia, secreted from the sheath of the tendon, for facilitating the 
motion of the tendon, and in abnormal distention of the sac. The 
sheaths of the tendons of the hand are most frequently affected. 
There is a gradual formation of a swelling in the hollow of the hand 
and lower end of the volar side of the forearm ; and we may distinctly 
feel the passage of a fluid in the sheath of a tendon from the vola 



528 TREATMENT OF GANGLION. 

manus to the forearm, under the ligamentum carpi volare and back 
again. The fingers are generally flexed and cannot be fully extended ; 
the movements of the hand and fingers are somewhat limited ; there 
is not necessarily any pain, and the patients do not usually apply to 
a surgeon till the disease has attained a high grade. 

Another form of this disease is partial hernial ectasia of the sheath 
of the tendon, with dropsy. On the sheath there forms a sac-like pro- 
trusion, about the size of a pigeon's egg", containing an abnormal 
amount of synovia of the sheath. 

Fig. 97. 




Diagram of the ordinary ganglion, a, tendon; J, sheath of the tendon with dropsical hernial 
protrusion upward ; c, skin. 

In ordinary surgical language this is called a ganglion when it 
comes on the back of the hand. It is of far more frequent occurrence 
than dropsy of the whole sheath of the tendon, but it only comes at 
certain places. Ganglia are most common on the dorsal surface of the 
wrist, where they arise from the sheaths of the extensor tendons ; they 
are more rare on the volar surface of the hand and higher up the fore- 
arm, rarer still on the foot, where I have found them most frequently 
on the sheaths of the peroneal tendons. These ganglia usually con- 
tain a thick, mucous, vitreous-looking jelly. The contents of previous- 
ly-described extensive exudations in the sheaths of the tendons ma} T 
also consist of clear jelly ; but frequently there are also innumerable 
white bodies, like melon-seeds, which are not organized, but usually 
consist of pure amorphous fibrine. These bodies may be present in 
such numbers that no fluid can be evacuated on puncturing these 
sacs. Sometimes we can diagnose these fibrine-kernels beforehand, 
from their giving rise to a strong friction-sound, such as occurs in 
subacute inflammation of the sheath of the tendons. 

In the treatment, we must, above all, bear in mind that w T e should 
avoid any operation that might induce suppurative inflammation of 
the sheath of the tendon, and might disable for a long time or possibly 
cause a stiff hand in a patient who had been but little inconvenienced 
by his ganglion. Remedies, such as mercury and iodine, which so 
stimulate reabsorption in cases of acute or subacute inflammation, are 
of little use here. The simplest and their most frequent operation is 
rupture of the ganglion. If, as is customary, the ganglion be on the 



TREATMENT OF GANGLIOX. 599 

dorsal surface of the hand, we take the flexed hand of the patient be- 
fore us, place the two thumbs close together on the ganglion, and 
make strong pressure ; this sometimes ruptures the sac, the fluid is 
effused into the subcutaneous tissue, and then readily reabsorbed. 
When this method succeeds readily, there is not much objection to 
it, except that it does not always cause a radical cure. The small 
subcutaneous opening of the sac soon closes, the fluid collects again, 
and the disease continues as before. If we cannot rupture the sac 
with the thumbs, it has been recommended to do so with a quick blow 
by a broad hammer; although this succeeds now and then, I would 
not recommend it to you, for if unskilfully done it may cause a severe 
contusion, whose consequences we cannot always master. When the 
sac is too thick to rupture with the finger, I employ subcutaneous dis- 
cision / I pass a narrow, short, curve-pointed knife (Dieffenbactts 
tenotome) horizontally into the sac, and with the point of the knife 
make numerous incisions on the inner wall of the sac, I then draw the 
knife slowly out, meantime pressing the fluid out of the sac. I then 
at once apply a compress, envelop the hand and forearm in a wet 
bandage, to prevent any extensive motion, and have the forearm car- 
ried in a sling four or five days. Then the bandage is removed, the 
small opening is healed, and the ganglion does not usually return, as 
it is apt to do after simple evacuation. The entire hernial sac has 
often been entirely removed, sometimes successfully without subse- 
quent inflammation, but at other times with suppuration of the sheath 
or loss of motion of the finger, so that I do not recommend this pro- 
ceeding to you. The difference in result after extirpation of these 
sacs may depend on whether there is a large or small communication 
with the sheath of the tendon, or whether there be none ; that the 
latter state does occur I have satisfied myself by examination of the 
cadaver ; but I cannot say whether in such cases the sac near the 
sheath of the tendon is newly formed, or whether the opening, by 
which most of these herniae of the sheaths communicate with the lat- 
ter, has been obliterated in the course of time. 

The treatment of extensive dropsies of the sheaths of tendons in 
the palm of the hand and forearm is much more difficult, since, for 
various reasons, subcutaneous discision is not available here, and re- 
sorbents are of little use ; the only thing left is to try other methods, 
which often at least induce some suppuration. Take into considera- 
tion then whether it be really necessary to do any thing severe. If 
the disturbance be not so decided as to greatly interfere with the pa- 
tient's business, you had better leave things alone. But, if something 
must be done, your choice is almost limited to two methods, viz. : an 
extensive incision and punction, with subsequent injection of iodine, 
34 



530 CHRONIC INFLAMMATION OF THE JOINTS. 

When you make the punction, which I prefer to incision, you should 
choose a trocar of medium size, as the fibrinous bodies will not escape 
through a very fine one. You will often have trouble in evacuating 
them even through a large canula ; then you will facilitate the opera- 
tion by injecting tepid water through the canula from time to time, so 
that the increased amount of fluid will aid the escape of the slippery 
fibrine-kernels. As alread} 7 mentioned, the quantity evacuated is often 
large. I once took one and a half tumblerfuls from a tendon-sac. After 
all has been removed, fill a syringe with an ounce of a mixture of 
equal parts of water and tincture of iodine, or a corresponding quan- 
tity of solution of iodine and iodide of potassium, and inject it slowly. 
Let it remain in the sac one to two minutes, and then escape slowly. 
Now remove the canula, cover the wound with a small compress, bind 
up the hand and forearm carefully, and put it on a splint. The patient 
should stay in bed several days. The operation is followed by a con- 
siderable swelling, due to collection of fluid as a result of acute in- 
flammation of the serous sac. If the tension become decided, we 
should remove the dressings, carefully close the puncture with plaster, 
then paint the swelling with strong tincture of iodine. In the more 
favorable cases, the swelling will then gradually subside, become less 
painful, and in the course of two to three weeks disappear entirely. In 
many other cases, however, there will be some, even if very temporary, 
suppuration, which may be checked and subdued with ice. In the worst 
cases there may be extensive suppuration of the sheath with necrosis 
of the tendon, and its results. Of course, opening the whole sac nat- 
urally induces suppuration. 

On this occasion I must again repeat that there may be hernial 
protrusions from the capsule of the joint, just as from the sheaths of 
the tendons, which may become dropsical without the dropsy extend- 
ing to the entire synovial membrane. The fibres of the capsule sepa- 
rate, and the synovial membrane passes between them into the sub- 
cutaneous tissue in form of the finger of a glove. Although such 
formations of round, pedunculated, long, wreath-like, and other shapes 
may develop from any joint, they are chiefly met in the knee, hand, 
and elbow ; in the latter I have often seen these isolated dropsies of 
hernias of the synovial sac communicating with the joint; they are 
accompanied by slight stiffness of the joint. 

I urgently warn you against operation on these ganglia of 
the joints ; this operation may be followed by suppuration of the 
joint. 

Cartilaginous bodies, enchondromata, sometimes even ossifying, 
occur in the tufts of the sheath of the tendons. Lipoma (L. arbores- 



GANGLIA OF THE JOINTS. 

Fig. 98. 



531 




Hernial protrusions of the synovial membrane of the knee-joint posteriorly (after W. Gruber). 
A. a, M. semimembranosus ; b, M, biceps ; c d, M. gastrocnemius ; e, M. plantaris ; //, sy- 
novial hernias.— 2?. a, capsule of knee-joint; c d, M. gastrocnemius; //, synovial hernia. 

cetis of J. Midler) has also been seen in the villi. The tumors should 
only be removed when they cause decided inconvenience. 



Here we shall also speak of fistulas and chronic dropsies of the 
subcutaneous mucous bursce. If one of these bursas be opened by a 
simultaneous skin-wound, we often have protracted suppuration from 
the sac, which is not dangerous, it is true, although there may be an 
extension of the suppuration to the subcutaneous cellular tissue, 
which, from its duration, may prove very annoying ; even after the 
greater part of the wound is healed, a tine opening remains; through 
this a probe may be passed into the sac ; a moderate quantity of serum 
is daily evacuated through this fistula of the mucous bursas. We may 
sometimes heal these fistulas by cauterization with nitrate of silver and 
compression by adhesive plaster; but in some cases they are very ob- 
stinate. Then you may attempt, by injecting tincture of iodine, to 
excite a more intense suppuration of the inner well of the sac, and 
thus cause it to atrophy or become adherent ; but a quicker way is to 
introduce a blunt-pointed knife through the fistula and slit up the 
sac and superjacent skin, so as to expose the whole interior ; granula* 



532 CHRONIC INFLAMMATION OF THE JOINTS. 

fcions will gradually spring up, and the wound will finally heal. I de- 
cidedly prefer this method. 

Dropsies of the subcutaneous mucous bursce are perfectly analo- 
gous to the above-described dropsies of the sheaths of tendons. Per- 
haps they may occasionally be caused by pressure or blows, but in 
many cases it is impossible to find any exciting cause. Although 
dropsies may occur in any of the constant, or occasionally in newly- 
formed subcutaneous mucous bursa?, they are particularly frequent in 
the bursa praepatellaris, which, according to JJi?ihart, often consists 
of two or three mucous bursas, lying over each other, sometimes en- 
tirely closed, at others communicating with each other. Dropsy of 
the bursa praepatellaris is very easy to recognize, for the tumor, which 
attains about the size of a small apple, is very evidently situated on 
the patella, and examination plainly shows that the sac containing the 
fluid does not communicate with the knee-joint. This disease often 
begins acutely or subacutely ; the fluid collects rapidly, the swelling 
is painful, the skin over it is red, and the patient cannot walk well. 
The terminations are various ; there is often entire reabsorption of the 
fluid, and a return to the normal state ; in other cases the reabsorp- 
tion is partial, the acute symptoms subside, and the state gradually 
becomes chronic. Rupture of the sac is one of the rarer terminations ; 
this may be subcutaneous ; the fluid is emptied into the subcutaneous 
cellular tissue, and induces diffuse inflammation. Rupture of both sac 
and skin is the rarest result ; the disease then runs the course of a 
punctured or incised wound of the bursa, of which we have already 
spoken. 

The form of the disease which is chronic from the start is more 
frequent than the acute. It begins slowly, without pain, and is more 
frequent in old than in young persons. In England this chronic 
dropsy of the bursa praepatellaris is called "housemaid's knee ;" there 
it is said to occur particularly among the servant-women who have to 
scrub the stairs on their knees. But it seems to me very doubtful 
whether this has any effect on the occurrence of the disease, for it has 
been shown by many anatomists that in a kneeling position the 
weight of the body does not come on the patella, but on the condyles 
of the tibia. To bring the anterior surface of the patella on the 
ground, it would be necessary to lie almost on the belly. 

The contents of these dropsical sacs are much less tenacious than 
those of sheaths of the tendons ; but not unfrequently these sacs also 
contain fibrinous bodies, which, on palpation, give a friction-sound, 
like that made by starch-meal when rubbed between the fingers. In 
the course of time the sac itself is thickened, the more so the older 
the disease. 



HOUSEMAID'S KNEE. 533 

Only the acute cases come under the surgeon's notice. They 
should be treated as follows : First of all, the patient should be kept 
quiet; then paint the swelling freely with tincture of iodine. Under 
this treatment the dropsy generally subsides rapidly; any remaining 
fluid you may attempt to remove by compression with adhesive plas- 
ter or bandages ; or you may from the first employ compression with 
wet bandages, or envelop the knee in wet compresses; mercurial 
salve and mercurial plaster are also of good service. 

Chronic dropsy of the bursa prsepatellaris usually causes so little 
inconvenience that it is generally of long standing before it comes to 
the surgeon's notice. Most persons scarcely have their movements 
impaired by the disease ; others say that they tire sooner than for- 
merly in the affected limb. The affection is usually limited to one 
side, but may attack both. It is generally very difficult to cure chronic 
dropsy of the bursa prsepatellaris by the remedies above mentioned. 
The trouble may be removed by operation. Tapping is no more a 
radical cure here than in other dropsies, as new fluid collects ; for tap- 
ping to prove efficacious it should be followed by injection of tincture 
of iodine. This is free from danger, if the patient subsequently keeps 
quiet ; the result is generally a radical cure. Another treatment is 
splitting up the sac, which is followed by its suppuration. If the sac 
be very thick, it is justifiable to extirpate it entirely, which, however, 
should be done very carefully to avoid injuring the adjacent capsule 
of the joint. JR. Volkmann has recommended a plan of treatment 
which I have often employed with good results, i. e., forced compres- 
sion ; a well-padded, hollow splint of tin or wood is applied to the 
back of the knee, and the knee is drawn as firmly as possible against 
it by means of flannel bandages ; this compression, which usually 
causes oedema of the foot, and sometimes severe pain, should be con- 
tinued several days. Reabsorption results, in two or three days, in 
small hygromata ; in six or eight days, in large old ones. I have seen 
very good results from this plan, not only in hygroma praepatellare, 
but also in dropsy of the knee ; in dropsy of the sheaths of the ten* 
dons it rarely does any good. 



534 CHRONIC INFLAMMATION OF THE JOINTS. 



LECTURE XL. 

C Chronic Elieumatie Inflammation of the Joints.— Arthritis Deformans. — Malum 
Coxa? Senile. — Anatomy, Different Forms, Symptoms, Diagnosis, Prognosis, 
Treatment. — Appendix I. : Loose Bodies in the Joints : 1. Fibrinous Bodies ; 
2. Cartilaginous and Bony Bodies ; Symptomatology, Operations. — Appendix II.; 
Neuroses of the Joints. 

C. CHEONIC EHEUMATIC INFLAMMATION OF THE JOINTS— CHEONIC 
AETICULAE EHEUMATISM— AETHEITE SECHE— EHEUMATIC GOUT— 
AETHEITIS DEFOEMANS— MALUM SENILE COX^E. 

You will be frightened at this crowd of names, which all refer to 
the same anatomical morbid changes, and you will rightly ask, Why 
so many names for the same thing ? When a disease has received so 
many designations, it is often a sign that its nature is not correctly 
understod, or that there have been various views regarding it at dif- 
ferent times ; but this is not the case here, for the process has always 
been regarded in the same way, and all observers fully agree in their 
decisions. It will be best to commence with the anatomy. The dis- 
ease chiefly affects the cartilage, secondarily the synovial membrane 
also, as well as the periosteum and bone ; in most cases the cartilage 
is primarily attacked. The changes that we find in the cartilage are 
as follows : In some places it becomes nodular, then rough on the 
surface, may be pulled into filaments, and, when the disease is far ad- 
vanced, it is altogether absent in places, leaving the bone exposed 
quite smooth and polished. If you examine the cartilage that is broken 
up into filaments, you will find even microscopically that the intercel- 
lular substance, which should be homogeneous, is filamentary. You 
also find that the cartilage-cavities are enlarged and contain cells, 
which are dividing up ; but these cells are not so small or slightly 
developed as is customary in cell-formations occurring in inflamma- 
tions ; they are well formed, and sometimes, from a somewhat thick- 
ened membrane, are recognizable as new cartilage-cells ; - the changes 
progress very slowly, and the newly-formed cells go on to a rather 
higher grade of histological development than in the above-described 
forms of inflammation (Fig. 99) ; the intercellular substance does not 
soften, as in inflammations generally, but breaks up into filaments ; 
this is a characteristic peculiarity of the disease, but there are also 
various others. The rough cartilage does not resist the friction of the 
articular surfaces, but is gradually rubbed through, and is worn down 
to the bone. 

Immediately under the cartilage there is always a layer, even if it 
be very thin, of compact bony substance; lying next to this are the 



ARTHRITIS DEFORMANS. 



53; 



spongy ends of the epiphyses ; after the cartilage is destroyed the 
friction affects this layer, and, as a result of the mechanical irritation, 
new bony substance is formed in this layer ; under the point of irrita- 
tion the medulla of the spongy substance ossifies to a slight extent. 
The adjacent bones are gradually ground off by the motions in the 




Degeneration of the cartilage in arthritis deformans: a, fatty defeneration of the cartilage- 
cells. Magnified 350 diameters, after O. Weber. 



joint, but, as the friction constantly causes the formation of new bone, 
the part ground off usually remains firm and smooth, as the hard- 
ening always precedes the atrophy from friction ; hence, if the joint 
remain movable, a considerable portion of the bone may be worn off, 
and the defective articular surface of the bone may still remain smooth. 
In the hip, these ground surfaces are at the upper surface of the head 
of the femur, and in the acetabulum ; in the knee, they are on the 
condyles, etc. In these changes the neck of the femur may be cov- 
ered with osteophytes in some places, while induration goes on at the 
smooth surfaces. The neck of the femur may be surrounded by osteo- 
phytes, and thus acquire a characteristic shape. This will sometimes 



536 CHRONIC INFLAMMATION OF THE JOINTS. 

come up in very peculiar forms ; in one place, atrophy, in another, 
formation of bone, in the same case, alongside of each other in the 
same bone. The disease not unfrequently begins as nodular prolifera- 
tion of cartilage, and ends with atrophy of cartilage. I think you are 
already acquainted with this combination of atrophy and new forma- 
tion in chronic inflammatory processes ; only call to mind caries, the 
type of ulcerative processes ; there we also saw destruction going on 
at the ulcerated surface, and extensive new formations around it. 

The above changes in the cartilage and bone are accompanied by 
some in the synovial membrane, which, however, do not differ much 
from those in chronic dropsy of the joint ; this contains a slightly-in- 
creased amount of synovia, which is cloudy, thin, and mixed with the 
ground-down particles of cartilage. The membrane itself is thick- 
ened, slightly vascular, the elongated tufts alone have more vascular 
loops in their apices. Parts about the joint may participate in the in- 
flammation — periosteum, tendons, and muscles. These occasionally 
ossify very slowly, so that the ends of the bones are often covered with 
bony masses ; this bony proliferation is sometimes very extensive. The 
form of these osteophytes is very different from those with which we 
are already acquainted ; they are flat and roundish, not shaped like 
pointed stalactites, but look like a fluid which had been poured out 
and stiffened while flowing ; moreover, they are not so porous as other 
osteophytes, but all the layers are of more compact bony substance. 
From these peculiarities, which you will at once notice on seeing a 
series of preparations, the appearance of this variety of articular dis- 
ease is even exteriorly so characteristic that, on seeing a macerated 
preparation of the bones, you would at once recognize the disease 
without knowing any thing of the special case. 

In this disease the new formation of bone probably takes such a 
peculiar form, first, because the process of development is so slow ; 
secondly, because here the ossification is not preceded by any special 
vascularity, as in osteophytes forming during the union of fractures 
in caries, necrosis, ostitis, etc. ; if , a tissue be very vascular when it 
ossifies, a porous bony substance must be formed, for the more vessels 
there are the more holes there will be in the bones. But in arthritis 
deformans the ossification is not preceded by any considerable new 
formation of vessels, the tissues ossify mostly just as they are ; perios- 
teum, tendons, even the capsule, ligaments, and muscles, and all this 
goes on very slowly ; this is why the bone formed is firmer. Sometimes 
also in the vicinity of the bone in the midst of the subserous cellular 
tissue detached points of bone form, which for a long time remain 
isolated round pieces ; subsequently they may perhaps unite with the 
other bony masses ; then they look as if glued on, and from the form 



POLYARTICULAR CHRONIC RHEUMATISM. 



53V 



of the bony growth we may often tell the course of its formation. 
These periarticular bony formations may cause entire dislocation of 
the joint and force it into an abnormal, half-luxated position ; they 



Pio. 100. 



Fig. 101. 



Fig. 102. 




Figs. 100 and 102, osteophytes in ar- 
thritis deformans. Fig. 100, low- 
er end of the humerus, dimin- 
ished; ^osteophytes; &, smooth- 
ed end of the bone. 



Fig. 101, carious elbow-joint, 
fungous inflammation of 
the joints, stalactite-like 
osteophytes, diminished. 



Fig. 102, os meta- 
carpi, I a and 
b, as in Fig. 100. 



may even render it entirely immovable. Sometimes these osseous 
formations grow into the joint, loosen from their attachments, and 
become loose bodies in the joint ; of which we shaU speak hereafter. 
Lastly, chronic dropsy may accompany this affection also, and you 
may readily understand that, from all these concurring circumstances, 
the joint may become so deformed as justly to deserve the name 
" arthritis deformans." But, I again repeat, that all these pathologi- 
cal changes never lead to suppuration. 

We now come to the clinical appearance of this peculiar disease. 
According to my experience, I should distinguish three forms of the 
disease : one, which is usually polyarticular and accompanied by con- 
traction of the muscles ; a second, which comes in one joint in young 
and middle-aged persons ; and a third, which only occurs in old age. 

1. Polyarticular chronic rheumatism (arthrite seche, rheumatis- 
mus nodosus, rheumatic gout) attacks young or middle-aged persons ; 
it is more frequent in women than in men, and in poor than in rich 
people ; badly-nourished, anaemic persons are especially liable to it ; 



538 CHRONIC INFLAMMATION OF THE JOINTS. 

it may originate in acute articular rheumatism or in a gonorrheal in* 
flammation of the joint ; after the termination of the acute or sub- 
acute disease of the joints, stiffness, pain, and swelling, remain in some 
of the joints, most frequently in the knees. But the disease may be 
chronic from the start, with moderate, unsteady pains in the joints. 
At first the patients use their limbs very well ; but in the course of 
months and years the mobility gradually decreases ; after exertion and 
catching cold, subacute dropsies of the joint come on, a part of the fluid 
may be reabsorbed ; but the joint always remains somewhat stiffer after 
every exacerbation, sometimes also it is enlarged. In the morning, 
when the patient rises, the limbs are so stiff as to be scarcely mov- 
able, though, after a few efforts, he gets along better for the rest of 
the day, but toward evening the joint again becomes painful. Now a 
new symptom gradually arises ; the muscles atrophy, the legs become 
thinner, and are fixed in a flexed position ; the atrophying muscles 
have great inclination to contract, which is constantly favored by the 
abnormal position of the joint. Meantime, the general health of the 
patient remains perfect; his appetite and digestion are good; he 
grows fat, and only has fever when there is an exacerbation of the 
joint-trouble. The joint is not very painful on pressure; if it be 
movable, we may feel and hear friction and grating sounds. This goes 
on for years. Finally, ihe patients emaciate greatly, the joints be- 
come deformed and stiff, or, as the laity say, " all drawn up ;" if the 
disease be in the hips or knees, they are bed-ridden, but with proper 
care may live for years; the knee, hip, wrist, ankle, and shoulder 
joints, are most frequently attacked. 

2. Arthritis deformans is almost always monarticular, rarely it 
attacks similar joints on both sides ; it occurs in persons otherwise 
healthy and strong ; I have seen it somewhat more frequently in men 
than in women. This form received its name from the fact that in it 
the periarticular periosteal formation of bone and the ground surfaces 
become so extensive that the joint is deformed. I have seen the dis- 
ease once in the hip, in both knees of the same person, once in the 
foot and elbow, and twice in the shoulder. Usually there is no assign- 
able cause ; in some cases it was preceded by luxations or sprains. 
These joints are generally painless, stiff, dropsical, and often contain 
loose bony bodies, and the synovial membrane may be covered with 
fatty tufts. 

3. Malum coxw senile. If the disease attack old people, it is 
usually somewhat milder than the bad forms of chronic rheumatism. 
The hip is the chief seat of the disease, hence the name " malum 
coxae senile," but it also comes in the shoulder, knees, and elbows, but 
especially in the fingers and ^reat toes of old people. Its commence- 



MALUM COX.E SENILE. 539 

ment is usually chronic, there is little pain, but much stiffness ; more 
rarely the initial stage is acute ; at first, the patients often complain 
only of stiffness, especially in the morning ; after the joint has been 
used, it grows more movable, the friction is often so marked that the 
patient calls the physician ? s attention to it. Attacks with severe pain 
and slight fever are most common where the fingers are the chief seat 
of the disease ; in the course of years the finger-joints are much de- 
formed. The great toe is dislocated outwardly, and the bony deposits 
on the head of the first metatarsal bone become very prominent. If 
the disease develop in the hip, the patients limp slightly ; in old per- 
sons the bony deposits are generally insignificant ; but the thigh is 
gradually shortened, from the wearing down of the head of the femur 
and the acetabulum ; the muscles atrophy, the hip gradually grows 
stiff; but this may not take place for years. The disease is much 
more frequent in men than in women, and thin people are most liable 
to it. It is rarely accompanied by disease of other organs, particu- 
larly the internal ones, but the affection is not unfrequently found in 
persons predisposed to chalky deposits and abnormal ossifications; 
rigidity of the arteries, ossification of the ribs and intervertebral car- 
tilages, and anterior spinal ligaments, are often present in patients suf- 
fering from malum senile. 

The diagnosis is easy; after the above description you would not 
readily mistake the disease. If the affection attack a single joint in 
a young person, we may at first be doubtful if it is a case of fungous 
inflammation or of arthritis deformans ; but, after further observation, 
the diagnosis will be easy. In the later stages it might also be mis- 
taken for fungous inflammation, with caries sicca, where we also find 
atrophy of the muscles and friction in the joint, and which also runs 
a very chronic course in young and otherwise healthy subjects; but in 
caries sicca there are never such extensive deposits around the joint, 
as in arthritis deformans, and, even when of long duration, the latter 
shows no tendency to suppuration. "When the chronic rheumatic 
articular inflammation occurs on both sides, or attacks several joints 
at once, and is accompanied by the reflex contraction of the muscles 
due to irritation of the synovial membrane, the disease cannot be mis- 
taken. Rheumatismus nodosus is often confounded with gout, because 
the effect of the two diseases on the hands and feet is somewhat simi- 
lar. But gout is so characterized by its specific attacks, and by the 
excretion of uric acid, that it should be regarded as a different disease ; 
we have already spoken about this. 

The prognosis of polyarticular rheumatism is very bad as regards 
recovery ; when it attacks old persons, I consider it entirely incurable. 
In young patients, by very careful, persistent treatment, the disease 



540 CHRONIC INFLAMMATION OF THE JOINTS. 

may sometimes be arrested at a certain point, and slight improvement 
be attained; but even this is very difficult, only a few cases are entire* 
ly cured. These unfavorable results are due to the anatomical prod- 
ucts of this disease ; the worn-down cartilage and bone are not re- 
placed, the bony deposits are not reabsorbed, they are too firm and 
solid ; the nutrition of the muscles fails to be excited by the natural 
motion of the limbs, for they are almost too weak to put in action the 
stiff limbs. When you have such a patient to treat, arm yourself with 
patience, and be not surprised if he consults first one then another 
physician, and finally all the quacks about, and lastly blames you for 
the origin and extent of his disease. 

Of course, even these patients must be treated; the surgeon cannot 
pick out the curable cases, the incurable and dying also have claims 
for his aid, and where we cannot aid we should at least try to alleviate 
and mitigate the disease. Chronic rheumatic inflammation of the 
joints, by its simultaneous occurrence at different points, shows that 
it is not due to a local injury, acting on a special joint, but frequently 
at least to a constitutional cause ; the enigmatical rheumatic diathesis 
is often blamed for the tendency to inflammation of the serous mem- 
branes, and exudations in the joints and muscles, hence, we employ 
antirheumatic remedies. The persistent employment of iodide of pot- 
ash, of colchicum and aconite, of diaphoretics and diuretics, is rec- 
ommended, although little benefit has been observed from them ; but 
there is nothing else that is better, at least nothing to act specially on 
the rheumatism. Besides these remedies, and those called for by 
special peculiarities of the case, warm baths are highly recommended, 
particularly the indifferent thermal baths : Wildbad in Wurtemberg, 
Wildbad-Gastein, Baden in Zurich, Baden-Baden, Teplitz, Ragaz in 
St. Gallen ; besides these, salt-baths may be given, especially where 
there is commencing muscular atrophy. Special attention should be 
paid to the climate of these watering-places, for all of these patients 
are very sensitive to cold, damp weather. Hot sulphur springs should 
be tried very carefully, and given up at once if a subacute attack occur 
after their use. If the patient live in a climate where the winter is 
cold and damp, he should be sent to winter in Italy, but, for fear of 
possible cold weather, should only go to places like Nice, Naples, Pa- 
lermo, etc., where the houses are well built. Damp dwellings should 
be most carefully shunned. The patient should keep warm, always 
wear wool next the body, and the affected joints should be wrapped 
in flannel. Water-cures are much recommended, and show some suc- 
cessful cures ; when sensibly used by physicians, and not simply by 
proprietors of the establishments, they are certainly appropriate, and 
often prove peculiarly advantageous by hardening the patient, and 



TREATMENT OE POLYARTICULAR RHEUMATISM. 541 

rendering him less susceptible to external influences, especially to 
catching cold ; moreover, drinking quantities of water, and the wrap- 
ping up after the baths, have a diuretic and diaphoretic effect ; besides, 
this mode of treatment has the advantage that patients will follow it 
out conscientiously and perseveringly, while they soon tire of taking 
medicines ; as is well known, hydropaths soon become enraptured with 
the system, and are very satisfactory patients even where the treat- 
ment is unsuccessful. Hence, if the patient be not too much debili- 
tated, and have no disinclination to the treatment (as sometimes 
happens), it should be tried, but should be continued at least a year 
to be of any real benefit. Russian vapor-baths have also been success- 
ful in some cases, as have also pine-needle baths. In badly-nourished 
patients the disease has also been cured by cod-liver oil, quinine, and 
iron. For local treatment we may rub in various things — the friction 
is doubtless the most important part of the application ; you may use 
iodine-ointment, simple grease, volatile liniment, etc. Strong deriva- 
tive remedies are of no use, and even tincture of iodine is only bene 
ficial in subacute attacks, in which cases blisters may also be tried 
Be careful about applying powerful irritants to the joint ; in chronic, 
torpid cases douches may prove very efficacious ; even hot or steam 
douches and local sulphur-baths have proved beneficial in some cases ; 
but in other cases even the mildest shower-bath, from a foot high, 
proves too irritating; we cannot always prophesy the effect, the 
patient should try it carefully under the supervision of the surgeon ; 
as soon as pain is excited, the douche should be stopped, and, after a 
period of rest, be tried with new precautions ; if the pains come on 
again, and increase, the douches had best be given up. 

Should the limbs be kept at rest or moved ? For various reasons 
perfect rest is not desirable : first, because the joint would become 
stiff, often in a very unfavorable position ; secondly, because absolute 
rest still more increases the atrophy of the muscles. Moderate motion, 
both passive and active, avoiding the excitation of pain or fatigue, 
should be made ; the patient may make the passive motions with his 
own hands, or with the very ingenious machine invented by JBonnet 
for this purpose. Lastly, we must add something about muscular 
atrophy. We attempt to strengthen the muscles by friction, elec- 
tricity, and regulated movements both active and passive ; here cura- 
tive gymnastics sometimes prove beneficial. But, to be of benefit, 
any of these methods of treatment must be followed perseveringly. 

From this therapeutical review you see we are not poor in reme- 
dies that may prove serviceable in chronic rheumatism, but all these 
modes of treatment are expensive and often unattainable by poor 
patients, and, as this class are peculiarly liable to the disease, they 



542 CHRONIC INFLAMMATION OF THE JOINTS. 

are very unhappily situated in regard to it. Since dry, warm air, good 
nourishment, protection from catching cold, and baths, are seldom 
to be found in the dwellings of the poor, and since these are ab- 
solute necessities for the treatment, the prescription of expensive 
medicines is a pure waste of money. Still, I again repeat, the sooner 
these patients come under treatment, the more recent the disease, the 
more you may expect from treatment. You may sometimes arrest 
the disease. If the malady be already far advanced, its arrest is more 
difficult, and a cure is rarely to be expected. I believe that most 
cases of malum coxa3 senile are incurable ; still, even there the above 
remedies form the rational treatment. Arthritis deformans monar- 
ticularis is incurable. If the joint be much deformed, you may resect 
it or amputate the limb. 



APPENDIX I. 

LOOSE BODIES LN THE JOINTS (MURES ARTICULARES). 

By these loose bodies in the joints, we mean more or less firm 
bodies, forming in a joint. We exclude foreign bodies entering the 
joint from without, such as needles, bullets, etc., or detached pieces 
of bone, lying loose in the joint. There are two varieties of loose 
bodies : 1. Small, oval bodies, resembling melon-seeds or irregular in 
shape, which usually form in large numbers, and on microscopical ex- 
amination are found to consist of fibrine. These form in joints with 
chronic dropsy, and are deposits from the qualitatively and quantita- 
tively abnormal synovia, just as the analogous bodies are in dropsy 
of the sheath of the tendons ; blood-clots may also possibly serve as 
a source of origin of such bodies. This form of loose bodies never 
requires any operation ; it is simply an accidental accompaniment of 
hydrops articulorum chronicus. Occasionally we may predict their 
presence from finding soft friction when palpating the joint ; this does 
not change the treatment of chronic articular dropsy, and only com- 
plicates it in that it renders more difficult the eventual reduction of 
the joint to its normal size. 

2. The other variety of articular bodies is of cartilaginous firm- 
ness, generally containing bone-nuclei, sometimes adherent, at others 
quite loose in the joint. The form is quite varied, being sometimes 
very odd. The name "joint mouse" (Gelenkmaus) may have arisen 
from some accidental shape, resembling a mouse. These bodies are 
always rounded, but seldom regularly oval or round, being usually nod- 
ular or warty ; their shape is that of the osteophytes in arthritis defor 



LOOSE BODIES IN THE JOINTS. 



543 



mans. Microscopically they consist of a thin covering of true filamen- 
tary or hyaline cartilage, which, from the centre, ossifies, or sometimes 
only calcifies. As these cartilages are mostly organized, they cannot 
be regarded as deposits from the synovia ; but, even if found quite 
free, they must formerly have 

been connected with and have FlG - 103 - 

formed in living tissue, and sub- 
sequently become detached. 
The actual process is as fol- 
lows : These bodies are mostly 
osteophytes, which have en- 
tered the joint from without ; 
rarely they form in the apices 
of the synovial tufts. Even 
normally there are sometimes 
cartilage-cells in the tufts ; 
these may proliferate, and 
thus in the tuft we should 
have a cartilage-nucleus, a 
cartilage-tumor, an enchon- 
droma, which subsequently os- 
sifies from the centre. For a 
time this tumor remains at- 
tached to the tuft, but finally 
it breaks off and then lies 
loose in the joint. But by far 
the most frequent form of these 
articular bodies is from the for- 
mation of ossifying cartilages 
(osteophytes) in the capsule 
of the joint immediately un- 
der the synovial membrane, 

which may enter the joint and finally tear loose and become free. It 
is probable that,when once detached and lying free in the joint, these 
bodies do not grow any more ; although it is not impossible that they 
might derive their nutriment from the synovia. The development of 
loose bodies is always accompanied by some dropsy of the joint ; per- 
haps the latter is occasionally the primary disease. Loose bodies 
occur almost exclusively in the knee-joint, and only in adult patients ; 
they are very rare, perhaps the rarest of articular diseases. There is 
an undoubted connection between the formation of articular carti- 
lages, arthritis deformans, and hydrarthrus. These diseases are of the 
same class, and from a possibly congenital or developed general diath- 




Multiple articular bodies, after Cruveilhier. 



544 CHRONIC INFLAMMATION OF THE JOINTS. 

esis they form a contrast to the fungous and fungous-s appurative 
articular inflammations. 

The symptoms which may be considered as characteristic of the 
existence of free bodies in the joint are as follows : The patient has 
long had moderate dropsy of the knee-joint, and, while walking, sud- 
denly has a severe pain, which prevents his walking for the time be- 
ing ; the knee stands between flexion and extension, and cannot be 
moved till it has been rubbed in a certain way. This symptom is due 
to the loose body being caught between the bones forming the joint, 
between the semilunar cartilages, or in one of the synovial sacs. But, 
even before this, these patients usually complain for weeks or months 
of weakness or slight pain in the knee, and, as already stated, exami- 
nation will generally show a slight amount of dropsy there. From 
the peculiar mode of occurrence and subsidence of the pain, the pa- 
tients themselves often suspect that there is a movable body in their 
knee-joint ; not unfrequently they can feel it distinctly, and can, by 
certain motions of the joint, render it perceptible to the surgeon. In 
other cases the surgeon does not feel the body till after several ex- 
aminations, and can move it around in various directions ; it often 
disappears again, and it may, be several days or weeks before it again 
comes in a position where it can be felt. These symptoms only be- 
come very evident when the body is detached. While still adherent, 
or, if too large to be caught as above mentioned, it causes little or no 
difficulty. 

Hence, although the inconveniences of a loose body and of a mod- 
erate dropsy of the knee-joint are not always great, and do not 
increase spontaneously, or go on to suppurative inflammation, and 
only have occasional subacute inflammation, with serous effusion after 
some exciting cause, still, in other cases, the pain from the squeezing, 
and the anxiety about being constantly liable to it, are so great that 
many patients imperatively demand aid. 

The attempt to fix these bodies by adhesive inflammation, induced 
either by a compressive bandage, tincture of iodine, or blisters, has 
had little success. The operation consists in the extraction of the 
foreign body ; it is done as follows : The loose body is pressed tightly 
under the skin, at one side of the joint; the skin- over it is then 
pressed strongly upward, and put still more on the stretch ; then cut 
through the skin and capsule down on to the body, and let the latter 
spring out, or lift it out with an elevator (perhaps an ear-spoon, as 
Fock has done) ; instantly close the wound with the finger, extend 
the leg, let the skin return to its normal position, so that the cut in 
it lies lower than in the capsule, and the two wounds do not commu- 
nicate directly ; the skin-wound is now to be closed with sutures and 



ANCHYLOSIS. 545 

plasters, and the limb extended on a splint ; a plaster-splint would be 
verv suitable here ; one might be made with a large opening and 
applied even before the operation. According to the symptoms of 
inflammation that arise, the treatment for traumatic inflammations of 
the joint is to be instituted. In former times these operations were 
very unfortunate ; they were not unfrequently followed by severe 
inflammations of the joint, and occasionally the surgeon had to con- 
gratulate himself if he saved the patient's life by amputating at the 
thigh. The modes of operation were often changed ; finally that 
above described, which is the simplest, carried the day. Fock per- 
formed this operation five times, always with success. The symptoms 
of inflammation were insignificant, and the patients could usually 
return to their occupations in a few weeks. As in the extraction of 
cataract or vesical calculus, much depends on the operation being 
well performed and without much bleeding or other hinderance. If a 
loose body causes no inconvenience, we may apply a knee-cap to 
limit the dropsy and give the joint a certain amount of firmness, so 
that there shall not be too much motion ; this often gives the patient 
great rest. 

APPENDIX II. 

NEUK0SE9 OF THE JOINTS. 

By neuroses and neuralgias we mean diseases characterized by 
typical or irregular pains whose causes we cannot find in any change 
of tissue. We assume that there is a functional disturbance in 
the nerves without morphological changes. There is no doubt that 
there are purely functional disturbances, which we call weakness 
and irritation, in the tissues, and especially in the nerves, where for 
our senses, even with all modern aids, no morphological or chemi- 
cal changes are discoverable, either during life or after death. We 
cannot say if such changes do nevertheless exist ; what we cannot 
perceive with our senses does not exist for us. So that state of the 
joint where there is pain for which we can find no physical cause is 
called a "neurosis of the joint." The pains are never typical, i. e., 
occurring at certain hours of the day in paroxysms, as in neuralgia 
of the trigeminus, for example. Brodie first classed neuroses of the 
joints as special diseases. Esmarch, Stromeyer, and Wernher have 
of late paid special attention to these affections ; according to them, 
the group should also include those cases, with slight but still per- 
ceptible anatomical changes, where pain and functional disturbance 
are the chief symptoms, and their severity is out of proportion to the 
apparent causes of disease. This would place neuroses of the joints 
35 



546 CHRONIC INFLAMMATION OF THE JOINTS. 

among hyperesthesias with their reflex complications ; in short, 
would class them with hysteria and hypochondria. The cases that I 
have seen, which from the descriptions of authors were to be placed 
in this class, I formerly regarded as slight diseases of the joints, 
whose symptoms were exaggerated in, or even simulated by, hyster- 
ical women and girls, or sometimes as commencing and not yet well- 
defined diseases of joints or bones ; and lastly, sometimes as great 
sensitiveness remaining after the disease had run its course. It is 
well to have a name for this group of cases, but they are not all to 
be viewed from the same point or treated in the same way. Gen- 
eral medical experience and knowledge of human nature must aid 
most in the treatment of hysterical patients ; the peculiarities and 
persistence of women in carrying out simulated contractions and 
spasms is incredible to any one but an experienced physician. Hys- 
teria is really a mental disease, often incurable, or only temporarily 
curable. For lessening the sensitiveness of joints we may try cold 
douches, baths, sea-baths, or active use of the joint ; the last is 
especially advised by Esmarch, Still, in just such neuroses, which 
had remained after disease of the joints, I have seen beneficial ef- 
fects from thermal mud-baths and electrical treatment. Benefit may 
also be expected from massage. 



LECTURE XLI. 

Anchyloses: Varieties, Anatomy, Diagnosis, Treatment; Gradual Forced Extension ; 
Operations with the Knife. 

You know that by anchylosis we mean a stiff joint, but I must add 
that this designation is used only when the process which causes the 
stiffness of the joint has ceased ; that is, when the limitation or total 
loss of mobility of the joint is the only morbid symptom present. For 
instance, if during an inflammation of the knee or hip the limb be 
strongly flexed by involuntary continuous contraction of the muscles, 
and the joint cannot be extended on account of the pain, although 
it should be mechanically possible, we do not call it anchylosis of 
the joint, but articular inflammation with contraction of the muscles. 

The causes why a joint cannot be extended after the subsidence 
of the acute inflammation are partly mechanical hinderances either in 
the joint or exterior to it, or in parts actually belonging to the joint. 
A muscle shortened by atrophy and shrinking, a strongly-contracted 
cicatrix of the skin, especially when on the flexor side of the limb, 
may greatly impair the normal mobility of the joint; such cases are 
not meant when we speak briefly of anchylosis; they are termed mus- 
cular or cicatricial contraction. Should we term these varieties of 



ANCHYLOSES. 547 

limitation of motion anchyloses, it is well to distinguish them as 
anchyloses from external causes, anchylosis spuria, etc. Now, we have 
left those cases of stiffness of the joints which are caused by path- 
ological changes of parts actually pertaining to the joint ; under this 
head we have the following cases : 

1. Cicatricial adhesions between adjacent surfaces of the joint 
itself ; these may differ greatly in variety and extent ; they form after 
cure of fungous articular inflammations, by adhesion of the prolifer- 
ating-granulating surfaces ; stringlike adhesions are thus formed, like 
those between the costal and pulmonary pleura, or else there are 
thick extensive adhesions of the surfaces ; along with this state the 
cartilage may be partly preserved, or it, together with part of the bone, 
may be destroyed. Generally, these adhesions, like other cicatrices, 
are formed of connective tissue ; in other cases, especially when the 
joint remains perfectly quiet, this cicatricial tissue ossifies, and the 
two articular surfaces are united by bony bridges, or else the entire 
surfaces are completely soldered together (Figs. 104-106). 

Fig. 104. 




Band-like adhesions in a resected elbow-joint from an adult, almost natural size. 

2. Further impediments to mobility are cicatricial shrinkages of 
the articular capsule, of the accessory ligaments, and even of the 
semilunar cartilages, which may also be entirely destroyed. These 
cicatricial contractions occur not only at places where fistulas have 
formed, but also when there has been no suppuration, for any tissue 
that has long been infiltrated, and so more or less softened, subse- 
quently shrinks some, after the process has run its course. 

3. A not insignificant impediment to mobility, and one which is 
the cause of its occasional non-recurrence after extensive funo-ous 

o 

inflammations of the joints, lies in the adhesion of the walls of the 
synovial sacs about the joint, which normally should glide over each 
other. To render this clear to you, I must touch on the normal con- 
ditions of the larger joints in motion. The capsule of the joint is 



548 



CHRONIC INFLAMMATION OF THE JOINTS. 



Fig. 10.* 




never so elastic as to adapt itself by this means alone to all positions 
of the joint. If you imagine a humerus lying on the thorax, then at 
the lower part of the joint the 
capsule would have to be 
firmly drawn together, above 
it would have to be greatly 
stretched ; if you imagine the 
arm raised as high as possible, 
the upper part of the capsule 
would have to be strongly 
drawn together, and the lower 
stretched; the articular cap- 
sule would have to be as elas- 
tic as rubber ; this is not the 
case : on changing the extreme 
positions of the joint, it con- 
tracts little or not at all; it 
folds up in certain directions ; 
if the position of the joint 
changes, the fold smooths out, 
and on the opposite side which 
was previously smooth another 
fold forms in the capsule. You 
here see perpendicular sections 
of the shoulder-joint, parallel 
to the anterior surface of the 
body (seen from the front, af- 
ter Henle) in an elevated posi- 
tion (Fig. I07),hanging by the 
side (Fig. 108). 

If the synovial membrane 
become diseased, the joint usu- 
ally remains in a certain posi- 
tion, the humerus is generally 
depressed, the lower part of 
the synovial sac (Fig. 108, a) 
may suppurate, shrink, and 
become adherent ; then, even 
if the joint were otherwise 
healthy, it would be impossi- 
ble to raise the arm, because 
the capsule at the lower part 
of the joint could not unfold. 



Complete cicatricial adhesion of the articular sur- 
faces of the elbow-joint of a child, the trochleas 
of the humerus and part of the olecranon de- 
stroyed ; section lengthwise, natural size. 



Fig. 106. 




Elbow-joint anchylosed "by bony bridges, resected 
from an adult ; about natural size. 

Anchyloses may thus result white 






ANCHYLOSES, 



549 



the cartilage remains intact; the secretion of synovia ceases, in 
the course of }^ears the cartilage may degenerate into connective tis- 
sue (as in old, immovable luxations), or may even ossify, and the 
anchylosis will thus become more immovable. Similar circumstances 
exist in almost all the joints ; you will find the best representations 



Fig. 107. 



Fig. 10S. 




SECTION OP THE SHOULDER-JOINT, SEEN FROM THE FRONT. 

Fig. 95, the capsule folded above, at a. Fig. 96, the capsule folded bplcw, at a. 

of these in TlenWs anatomy. H. ~Volkmann had previously described 
this variety of anchylosis, which occurs especially often in young 
persons after subacute coxitis without suppuration, but with great 
tension of the muscles, as " cartilaginous anchylosis." The name is 
well chosen, in so far as in them the cartilage long remains intact. 

4. A further mechanical obstruction may lie in the bony deposits 
which form in the joint on the articular surfaces of the bones impli- 
cated ; for instance, if the fossa sigmoidea, anterior or posterior of the 
lower end of the humerus, fill up with newly-formed bone, neither the 
processus coronoideus nor anconeus of the ulna can enter it, and in the 
former case the arm cannot be fully flexed, in the latter it cannot be 
fully extended. This hinderance is most common in arthritis de- 
formans ; it is rare in fungous inflammations of the joint (Fig. 101). 

5. Lastly, as a result of caries of the ends of the bones, there may 
be such loss of substance that the epiphyses will stand obliquely to 
each other and cannot be brought into position again, because their 
surfaces are too much changed, and do not fit on each other in the 
abnormal position (pathological luxation), or cannot be moved at all. 
Examine Fig. 105 again ; as a sequence of the destruction of the 
trochlea humeri, the ulna is so drawn toward the humerus that, even 
if some motion were possible, complete flexion could not take place, 
because the processus coronoideus strikes on the humerus anteriorly, 
as the fossa sigmoidea is absent. In caries of the knee also the tibia 



550 CHRONIC INFLAMMATION OF THE JOINTS. 

may be half dislocated outwardly and posteriorly, so that the sui faces 
which belong together no longer lie in apposition, and in the abnormal 
position there is no motion at all, or only a slight amount. 

Besides these causes of immobility which lie more or less in the 
joint, there may be external ones, especially the above-mentioned 
muscular contractions, as well as cicatrices which may become adherent 
to the muscles, tendons, or bones, and thus materially aid in fixing 
the joint in a false position. 

Generally, the diagnosis of anchylosis is not difficult ; but it may 
not be easy to decide which of the above-mentioned factors should be 
blamed for the deficiency or entire absence of motion. When the 
stiffness is complete, we readily suppose that there is bony anchylosis, 
but this is not always the case ; very short, strong adhesions, espe- 
cially if very broad, must also cause absolute immobility. The longer 
such an anchylosis remains entirely immovable, the greater the prob- 
ability that there is bony anchylosis ; even when the joint is propor- 
tionately little diseased, and the greater part of the articular cartilage 
is normal, if the joint has remained at rest many years (perhaps only 
as a result of shrinkage of the capsule), complete bony anchylosis w T ilI 
often form gradually ; for even a healthy joint will finally become 
anchylosed if kept immovable for years ; motion is an absolute ne- 
cessity for the continued health of the synovial membrane and carti- 
lage ; you may even conclude this to be the case from the fact that all 
the articulations which are subject to little or no motion (as the inter- 
vertebral, pelvic, and sternal), have a very slightly-developed synovial 
membrane, and are very deficient in cartilage. When the motion of 
the joint ceases, the secretion of a useful synovia is arrested, the sy- 
novial membrane becomes dry, tough, the cartilage becomes filamen- 
tary, and the entire beautiful apparatus finally changes to a cicatricial 
connective tissue which may ossify ; then the function of the joint 
ceases. We have made these statements for the purpose of calling 
attention to the possibility of deciding, from the duration of an im- 
movable anchylosis, about its firmness. But if the anchylosis be mov- 
able, even if very slightly, the synovial membrane is rarely destroyed ; 
part of the cartilage also is usually preserved in such cases. We may 
be greatly deceived as to the mobility or immobility of anchylosis, if 
we leave out of consideration the tension of the muscles ; frequently, 
we do not fully comprehend the amount of this mechanical hinderance, 
till we arrest the muscular contractility by anaesthesia, which must 
be pushed to the point of total relaxation of the muscles. 

Now, what is to be done for these anchyloses ? Can we render the 
stiff joint movable again ? In most cases this question can be an- 
swered affirmatively. Can we permanently preserve this mobility and 



EXTENSION OF ANCHYLOSES. 551 

restore the normal function even approximately ? Unfortunately, this 
is rarely possible. What shall then be done ? What, then, is the use 
of treatment ? This latter question is sometimes a just one, but is 
not usually so. We have already said that, in inflammations of the 
joints, the limbs usually assume an abnormal position, a position in 
which they are very unserviceable ; a leg bent at right angles at the 
knee is a useless, unnecessary burden, hence such limbs were formerly 
amputated, as the patient could go about better with a good wooden 
leg than with two crutches. An arm entirely extended at the elbow, 
or only slightly flexed, is also a very inconvenient member, and very 
unsuitable for seizing and holding objects, etc. By simply bringing 
the anchylosed limb into a position where it is relatively most useful, 
as the knee into the extended position, the arm to a right angle, we 
may do the patient much good ; hence, these operations of straight- 
ening or bending anchyloses are very satisfactory. Anchyloses in an 
inconvenient position were very frequent for a time ; they are becoming 
rarer, and will disappear entirely as soon as universal attention is paid 
to the principle we urge of placing the joint in the best position for 
anchylosis, when we are treating acute or chronic inflammations. No 
surgeon of modern times will have occasion to operate on anchylosis 
for the improvement of position, in a patient that he himself treated 
for inflammation of the joint. But there are still many cases that 
have to be treated in the country under most unfavorable circumstances, 
where angular anchylosis of the knee or hip results, so that extension 
of anchylosis is still among the tolerably frequent operations. 

Attempts to straighten deformed and stiff limbs are quite old. 
Even in the surgical writings of physicians of the middle ages we find 
illustrations and descriptions of machines constructed for this pur- 
pose, for the method of relieving the deformities by slow extension 
with machinery is the older. A large number of apparatus for the 
various joints have been constructed, by w 7 hose aid the extension and 
flexion of the extremities may be induced by the action of a screw. 
Now these instruments are chiefly employed in cases where it is 
thought that, while straightening the joint, we may retain its mo- 
bility ; but as these cases are very rare, and as they also may be really 
improved by rapid extension, these machines are much less used. In 
contradistinction to slow extension of anchyloses, we have the rapid, 
forcible extension, which is falsely termed brisement force. Before 
chloroform was known and employed in these cases, this operation 
was, on many accounts, objectionable. It was very painful, and not 
free from danger ; it required a great deal of power in the forcible ex- 
tension of anchylosis for breaking and tearing them up ; this was due 
not only to the obstructions in the ioint, but also very greatly to the 



552 CHRONIC INFLAMMATION OF THE JOINTS. 

muscles, which contracted strongly as soon as the pain began. Hence, 
before trying to extend the anchyloses, it was often necessary to di- 
vide the tendons of the tense muscles ; this complicated the operation. 
Moreover, the after-treatment was not correctly understood : the ex 
tended limb was bound to a splint, or held firmly by machinery ; the 
consequences were severe inflammation and great swelling; the 
method did not become popular. Bouvier and Dieffenbach were al- 
most the only ones who occasionally resorted to it ; other surgeons 
preferred to consider these patients as incurable, or to send them to 
orthopedists for gradual extension, or, if the patients were poor, to 
amputate the limb, so that they might have a wooden leg to go about 
on more securely. So the matter stood till B. von Langenbeck in 1846 
made the first attempt to extend an anchylosed knee-joint while the 
patient was anaesthetized. This showed the interesting fact that under 
anaesthesia the contracted muscles become perfectly relaxed and pli- 
able, and may be stretched like india-rubber ; this rendered tenotomy 
and myotomy unnecessary in this operation. As anaesthesia rendered 
the operation painless, it could be done more slowly and carefully, 
and with the aid of the hands alone. The results were so very favor- 
able that this method, which in its new form scarcely deserved any 
longer the rather brutal name of " brisement force," soon became uni- 
versal, and now it has, perhaps, too much displaced extension by in- 
struments and weights. The method of the operation, the indications, 
the precautions to be observed, and the after-treatment, were gradually 
so perfected by B. von Langenbeck that this operation may be re- 
garded as one of the safest and simplest in surgery. To prevent 
your being misled by the name " brisement force," and forming too 
horrible an idea of the operation, I will describe for you the exten- 
sion of a knee bent at right angles. At first the patient lies on his 
back, and is gradually anaesthetized so deeply that all the muscles are 
relaxed, and no reflex movements occur. When this state has been 
reached, the patient is turned on his belly ; one assistant holds the 
head, another places his arm under the breast of the patient to facili- 
tate respiration ; the pulse and breathing are carefully watched, for 
the operation must be interrupted at once if dangerous symptoms fol- 
low the deep anaesthesia. The patient, lying on his face, is to be 
drawn toward the lower end of the operating-table till the knee 
comes to the edge of the table, which should be covered by a firmly- 
stufl'ed horse-hair cushion. Now an assistant with both hands presses 
as strongly as possible on the thigh ; the operator stands at the outer 
side of the left (anchylosed) knee, places his left hand in the popliteal 
space, so as to depress the thigh, and the right on the posterior 
surface of the leg, corresponding to the posterior surface of the con- 



EXTENSION OF ANCHYLOSES. 553 

dyles of the tibia, that is, close above the calf, and with his right 
hand he makes downward pressure on the leg. If the anchylosis be 
still recent, and not too firm, the leg will gradually give way with a 
perceptible soft crackling and tearing, and will be straightened by 
degrees. Should extension not be made so readily, the operator 
places his hand lower on the leg, about the calf or close below it ; 
but then he should not use so much force as he could above, because 
he might readily fracture the tibia just below the condyles, especially 
if the bones were a little soft ; the force should here act more in the 
way of traction or extension. If we do not succeed even by this last 
means, we should attempt to rupture the adhesions by strong flexion ; 
we seize the leg from the front and try to flex it by slow, regular press- 
ure ; by this means the adhesions sometimes rupture more readily 
than by movements toward extension ; after a few of the adhesions 
have been torn, extension is generally easy. All painful twisting 
and wrenching is decidedly injurious, and very rarely does any good. 
When we have made as much extension as we consider prudent for 
one operation, or, if the leg be fully extended, we turn the patient on 
the back again, let the assistants press down the thigh by means of 
Hueter's bandages, extend the leg by the foot, and from the foot to 
within an inch of the perinseum apply a stout plaster-of-Paris dressing, 
inserting thick layers of wadding at the knee and at the ends of the 
bandage (below and above, where there is most pressure). But, as 
the plaster does not always harden before the patient recovers from 
his anaesthesia, we bind a well-padded hollow splint to the flexor side 
of the limb, to prevent the knee contracting again ; this hollow splint 
is to be removed after three or four hours ; by that time the plaster- 
dressing is hard enough to resist the contracting muscles. The pain 
that the patient suffers after recovering from his anaesthesia is not al- 
ways severe, often it is remarkably slight in proportion to the force 
employed. The foot sometimes becomes eedematous, if it has not 
been properly bandaged ; but if this has been done, or is done im- 
mediately after the operation, there is no further trouble. Should the 
pain be very severe directly after the operation, we may apply a blad- 
der of ice over the plaster-bandage, and give a quarter of a grain of 
morphia. After eight or ten days we may allow the patient to grat- 
ify his wish of getting up with the bandage on, and going about on 
crutches, or with sticks. After eight or twelve weeks the anchylosis 
has healed in its new position. Meanwhile, the patient has thrown 
aside his crutches, and goes about with a stick, perhaps even with- 
out any support, his knee being stiff, but straight ; then the bandage 
may be removed, and the patient regarded as cured. 

In the above case we have supposed that an operation succeeded 



554 CHRONIC INFLAMMATION OF THE JOINTS. 

in straightening the knee. But this is not always the case ; fre- 
quently at the first operation we dare not go so far without risking 
serious consequences. What circumstances can prevent our complet- 
ing the operation at one sitting ? These are chiefly extensive cica- 
trices of the skin, which demand very great precautions ; cicatrices in 
the hollow of the knee are especially difficult to deal with, and must 
be extended gradually ; they would be torn if we tried to force the 
extension. Occasionally, also, the cicatrices surround large vessels 
and nerves, whose sheaths may have participated in the previous ul- 
ceration, and tearing these parts would be a very serious, perhaps 
fatal complication. Breaking up of any cicatrix may be followed by 
suppuration, or even mortification; hence we should never stretch 
cicatrices of the skin to the extreme point to rupture them. Hav- 
ing reached the point where the cicatrices are very tense, we should 
stop, apply the dressing, and repeat the operation in four to six 
weeks, and so on till we accomplish our object. 

A further circumstance requiring attention is the faulty position 
of the tibia, that may have resulted from caries of the knee, especially 
its inclination to luxation backward ; it is always difficult, sometimes 
impossible, to correct this position of the knee, but we succeed best 
by making the extension very gradually ; under such circumstances, 
forced extension would induce luxation backward — then perfect 
straightening would be impossible. 

You must not expect that the knee will again acquire its beautiful 
normal shape, even if it be quite straight ; this never occurs, but, as 
we are not called on to go about with naked knees, as the Highlanders 
do, the shape does not make so much difference, if the knee be only 
straight and firm enough to walk on. Although joints with tumor 
albus may be brought into the most serviceable position at almost any 
time, even when there are fistulas present, and should be placed in a 
closed bandage or knee-cap, still, the period when fistulas have just 
closed, and the cicatrices are fresh, dense, and tender, is most unfavor- 
able for the extension, for then rupture of the cutaneous cicatrices 
and new suppuration will be most liable to occur. In such cases I 
now never resort to sudden straightening under anaesthesia, but always 
employ extension by weights. 

What has here been said in regard to straightening the knee-joint 
may apply equally to the hip and ankle. Anchyloses of the shoulder 
and elbow have a totally different functional significance ; in them the 
problem is to restore mobility, and this cannot be obtained by break- 
ing up the anchylosis and applying a plaster-bandage. 

If, on straightening a knee, where there have been few adhe- 
sions, and the joint is tolerably healthy, we wish to obtain mobility, 



OPERATIONS FOR ANCHYLOSES. 555 

of course we should not apply the plaster-bandage after the operation, 
or, at least, should not leave it on long, but we should apply instru- 
ments by which, motion may be made some time after the extension ; 
this motion should first be tried under anaesthesia, and subsequently 
repeated daily without the anaesthetic. I shall not deny that cases 
occur where a tolerable amount of motion may be obtained in this 
way; but they are rare, and they are either cases where stiffness 
has remained after fractures through the joint, or after inflammations 
of very short duration ; I could almost believe that, in some of these 
cases, mobility would have been restored simply by daily use, hence I 
have no very brilliant anticipations about the results of straightening 
anchyloses generally. But the mere fact, that we may now almost 
entirely erase anchylosis from the list of indications for amputation, 
is a very great triumph over former surgery ; but this does not bar 
the way for further improvements of the new method, or for the at- 
tainment of better results. 

[Wharton P. Hood (in " Bonesetting," London, 1871) says that 
partial anchylosis and pain on motion are often due to string-like ad- 
hesions. A painful point exists somewhere about the joint; you 
should press on this with the thumb of the left hand, while steadying 
the limb above the joint, then with the right hand make sudden flexion 
and rotation, again extend the limb and let the patient use it at once. 
Of course this is not to be done if any acute inflammation exists, or 
in scrofulous subjects.] 

Cases occur where the mechanical conditions in the joint are of 
such a nature that the ends of the bones cannot be brought into any 
different position. I have already given you the elbow-joint as an 
example ; e. g., the case is one of arthritis deformans, the fossae at 
the lower end of the humerus above the trochlea are filled with 
newly-formed bone ; here it is impossible to move the ulna forward or 
backward ; in arthritis deformans similar circumstances occur in other 
joints, hence the consequent anchyloses cannot be rendered movable, 
any more than they can after true arthritis, therefore both diseases 
are usually contraindications to extension of the anchylosis. Lastly, 
as above stated, the adhesions of the ends of the bones may be bony, 
there may be anchylosis ossea; it will rarely be possible, indeed, except 
where there are simply a few osseous bands, to break such anchyloses ; 
in most of these cases the anchylosis will stand firm. What can be 
done in such cases ? There are two ways of altering the position of 
such joints: by bending the bone above or below the anchylosed 
joint, or by sawing out a piece from the joint or from the bone. In 
regard to the first, some surgeons would shrug their shoulders if it 
were proposed as a method ; still, this bending or even fracture of the 



556 CHRONIC INFLAMMATION OF THE JOINTS. 

bone has often been done unintentionally, and has generally turned 
out well. Several times in extending anchylosis of the knee-joint, 
once in the hip- joint, without intending it, I made a partial or com- 
plete fracture of the bone ; the joint remained as before, but above 
the knee and below the hip the bone bent so as to compensate for the 
angle at which the joint was anchylosed, and straightening was prac- 
tically accomplished, although not by rupture of the anchylosis. In 
all these cases I applied the plaster-bandage ; the course was just the 
same as in simple subcutaneous fractures, the pain was even less 
than after breaking up anchyloses, and the result was perfectly satis- 
factory. I cannot see why we should reject this operation of substi- 
tuting a fracture of the bone for an unsuccessful attempt at straight- 
ening the anchylosis, and I should much prefer it to any resection of 
the knee or hip, where it can be done easily, without great force or 
hard jerks ; I even believe that we should always try to substitute 
fracture of the femur, if it can be easily broken, for resections of the 
knee at least, no matter how they are done ; in other joints resection 
is of course to be preferred for various reasons. The perfected meth- 
ods of extension by weights not only enable us to improve the posi- 
tion in most cases of acute and chronic inflammations of the knee and 
hip joints with unexpected facility, thus avoiding angular deformity ; 
but even in developed anchyloses they prove very effectual, except- 
ing., of course, cases where there is bony anchylosis. Hence extension 
by weights seems to come more into use and to be an adjuvant to 
treatment by apparatus as well as by brisement force. 

There are three methods of resecting bony anchylosis : 1. Rhed 
Bartorfs (published in 1825) ; in angular anchylosis of the knee, 
after dividing the soft parts, close above the joint, you saw out from 
the femur a triangular piece, whose base is upward, and whose angle 
pointing downward must compensate the angle of the anchylosis (we 
might also saw this piece out of the anchylosed joint itself) ; then 
the limb is straightened, the joint is untouched, the distortion is 
placed in the thigh, as it is after fracture of the bone. This operation 
lias been done frequently with good results in anchyloses of the hip 
and knee. 

2. We may make a subcutaneous osteotomy through the anchylosed 
joint after JB. von Langenbectfs method ; this operation, which we 
found to be very useful in fractures that had united obliquely and in 
rachitis (page 232), has hitherto been little used in bony anchylosis, 
hence we can give no opinion of it. Gross has employed a modified 
form of it with great benefit ; he bores obliquely through the anchy- 
losis in many places, and divides the adhesions with fine chisels. 



OPERATIONS FOR ANCHYLOSES. 557 

3. Total resection of the joint. I have already stated my opinion 
about the admissibility of resection for anchylosis of the hip and 
knee-joints, and would regard it as ultimum remediwn and valde 
anceps; in the elbow-joint the prospect is rather better; here by re- 
section we may change the anchylosed joint into a movable false one, 
which is occasionally quite useful, if all turns out well, but this is the 
point on which all depends, and which we cannot always master. 
Who would risk his life for a stiff elbow ? Moreover, in resections 
for anchylosis of the elbow, the results have not always been very 
brilliant, either as regards mobility or life, although some cases seemed 
for a time very successful. So we should not be too free with these 
resections. 

In the shoulder, the circumstances are very peculiar : experience 
teaches that persons with stiff shoulders can, by constant use, make 
their shoulder-blades so movable that the stiffness of the shoulder 
causes comparatively little inconvenience ; in such a case it would be 
folly to operate. 

Patients with caries of the wrist are usually so glad, when, after 
years of suffering, the disease at length recovers, that they do not 
complain of their stiff hand ; nevertheless, successful resections of an- 
chylosed wrists have been recently made by Hose / it is true, the final 
results of these operations are not yet fully known. In the foot there 
would be no question about resection for anchylosis in a bad position ; 
usually defect of the ankle-bones is the chief cause of deformities of 
the foot after inflammation of the joint. It will depend on the indi- 
vidual case whether the foot is useful, whether a correction of posi- 
tion be possible, or if a good stump be preferable. 



CHAPTER XVIII. 

CONGENITAL DEFORMITIES OF THE JOINTS, DUE TO MUS- 
CULAR AND NERVOUS AFFECTIONS AND CICATRI- 
CIAL CONTRA CTIONS—L OXARTHROSES} 



LECTURE XLII. 

I. Deformities of Intra-uterine Origin due to Disturbances of Development of the Joint. — 
II. Deformities occurring only in Children and Young Persons, caused by Impaired 
Growth of the Joint. — III. Deformities from Contractions or Paralysis of Single 
Muscles or Groups of Muscles. — IV. Limitation of Movement in the Joints from 
Contraction of Fasciae and Ligaments. — V. Cicatricial Contractions. — Treatment : 
Extension by Apparatus. — Straightening during Anaesthesia. — Compression. — Te- 
notomy and Myotomy. — Division of the Fasciae and Articular Ligaments. — Gym- 
nastics and Electricity. — Artificial Muscles.— Supporting Apparatus. 

Geisttlemek : Today we have to speak of those deformities not 
resulting from primary disease of the joint, but leading to abnormal 
mechanical conditions, if the articular surfaces from various causes 
assume abnormal forms, or if while the form remains normal the move- 
ments be impaired in some direction by obstacles due to abnormal 
states of the muscles, fascias, tendons, or skin. Most of the cases are 
of stiffness, deformity, or limitation of motion of the joint, exterior to 
the synovial membrane. In this section I follow chiefly the division 
of Volfanann, whose extraordinary work on this subject, published 
in Billroth and Von PithcCs Archives, I cannot too strongly urge 
your studying. 

I. DEFORMITIES OF EMBRYONAL ORIGIN, DUE TO DISTURBED DEVEL- 
OPMENT OF THE JOINT. 

These distortions are always congenital ; they are much the most 
frequent in the foot, especially as club-foot, pes varus sea equino- 
varus. Although we may, and formerly did, term all distortions 
where the foot was drawn together into a " clump " as club-foot, we 

1 From Ao£o?, oblique, ap9pov, member, joint. 



CLUB-FOOT, ETC. 559 

now generally mean by this term only the forms where the inner 
border of the foot is raised, while the plantar surface is usually flexed, 
and in children it cannot be brought into the normal position, unless 
with the greatest difficulty. If children born with such feet (both 
feet are usually affected) learn to walk, they step on the outer side 
of the foot ; this rolls more and more inward, becomes flat, the hol- 
low of the foot is contracted, the middle and anterior part of the foot 
are not well developed, the joints become anchylosed and the feet 
become misshapen clubs ; the outer part of the back of the foot is the 
part walked on, and at that point a thick callosity forms with a mu- 
cous bursa under it ; as the foot is not moved, the muscles of the 
leg atrophy, so that little besides skin and bone is left ; this causes 
the resemblance to a horse's hoof. Various grades of club-foot have 
been distinguished, from the trifling deformity just after birth to that 
just described. It is to be remarked that the higher grades of club- 
foot result from walking ; if the patient never got on his feet, the con 
genital deformity would probably change little, if any. 

The most varied hypotheses have been advanced as to the causes 
of congenital club-foot. The typical form of this congenital deformity 
appears to indicate that it depends on disturbance of a typical devel- 
opment of the lower extremities ; for if foetal disease, disturbance of 
an irritative nature, or abnormal pressure in the uterus, were at fault, 
cases would probably differ, as we shall see hereafter. The following 
views, recently published, seem to me very important in the explana- 
tion of this deformity. Eschriclit has shown that at the commence- 
ment of their development the lower extremities lie with their backs 
against the abdomen, the hollows of the knees being against the belly; 
so during the earlier months the legs must rotate on their axes, and 
the toes, which pointed, backward, must point in the opposite direc- 
tion. If the embryonic extremities lie so close as to appear united 
under a common skin, or be really united, the above-mentioned rota- 
tion of the limbs cannot occur, and in this deformity {siren) the feet 
are turned directly backward. This rotation on the axis, which was 
arrested in the above case, does not take place fully in club-foot, ■ 
the rotation in the foot is not fully accomplished. According to this, 
congenital club-foot would come among cases of obstructed develop- 
ment ; about its cause we know as little as we do of other deformities 
of the same class. The abnormal forms observed by Siieter, espe- 
cially the obliqueness of the ankle-bones, unsuitable length of the mus- 
cles, among which shortness of the gastrocnemius is the most con- 
spicuous and longest known, must be regarded as consequences of 
this faulty direction of the foot in utero, which is subsequently in 
creased. This explanation, based on accurate observation, is so much 



560 CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 

more satisfactory than the previous hypothetical explanations, which 
mostly referred the affection to foetal myelitis, with consecutive paral- 
ysis and contraction, that the latter scarcely deserve mention except 
for their historical interest. 

Some other congenital deformities of the feet are proved to be 
due to abnormal positions, and especially to abnormal pressure. 
VblJcmann has collected some very interesting observations on this 
point ; but these cases differ among themselves, showing that there 
was something accidental in their occurrence. In still other cases 
large portions of bone remained undeveloped, e. g., the lower end of 
the tibia, fibula, or radius, or the whole radius (manus vara). 

In the spinal column, lateral halves of the vertebrae sometimes do 
not develop fully, or superfluous pieces may be formed, causing lat- 
eral curvature (scoliosis) ; but these congenital cases of curvature are 
very rare ; the Vienna collection has a few of these rare specimens. 
Lastly, we must here mention the faulty development of the sterno- 
cleido-mastoid muscle, which is not rarely congenital and is quite 
typical ; the vertebrae remain normal, so far as is known ; we know 
nothing of the causes of this deformity ; the hypotheses I have seen 
seem to me scarcely probable. 

II. DEFORMITIES DEVELOPING ONLY IN CHILDREN AND YOUNG PER- 
SONS, CAUSED BY DISTURBED GROWTH OF THE JOINTS. 

All conditions of the body, such as standing, walking, sitting, etc., 
depend on the forms of the joints and their ligaments, and on muscu- 
lar action. The effect of the latter on all our positions, even in the 
way we lie, you may best perceive by trying to give a certain position 
to a cadaver, from which the rigor mortis has passed away ; you 
would then see that we rarely take the natural positions given by the 
form of the joints and ligaments, but generally aid them by the mus- 
cles. Persons whose muscles tire easily, from weakness, exhaustion 
from disease, or lack of exercise, in assuming any position will of 
course seek the one most natural, and requiring least muscular action. 
The articular pressure due to muscular action is always evenly dis- 
tributed over the whole articular surface, and, when this action dimin- 
ishes or ceases, individual parts of the ends of the bones forming the 
joint have to bear all the pressure. If the bones were fully developed 
and firm, this unusual burden would have no further results, if it were 
of short duration. But when growing bones, which are still soft, and 
will remain so for a time till their forms are fully developed, are re- 
peatedly and for a long time exposed to pressure, acting on the same 
point, the form of the articular surface and of the articular ligaments 
gradually changes; the bones also sometimes fall into a state of 



DISTURBED GROWTH OF THE JOINTS. 561 

pathological softening, accompanied by pain and the disturbances of 
growth in the ends of the bones caused by the abnormal burden, in- 
crease rapidly ; there is a corresponding change in the ligaments and 
muscles, and the changes begun here, react on the form and develop- 
ment of the entire skeleton. The most important examples of this 
are scoliosis, genu valgum, and pes planus. 

By " scoliosis " (from okqXioc, curved) we mean the state of the 
spinal column, where it is constantly bent to one side, and where this 
curvature has become permanent. As already mentioned, such a po- 
sition may arise from abnormal formation of the vertebrae ; it may also 
be due to enormous distention of one side of the thorax from pleuritic 
effusion, or to collapse of one side of the chest from reabsorption or 
evacuation of such effusion, or lastly to fixation of the pelvis in an 
oblique position, either from apparent or real shortening of a leg after 
a joint or bone disease, or other cause. All these are relatively 
rarely the causes of the scolioses of which we are here treating ; these 
usually occur in young girls shortly before puberty. These curva- 
tures have a typical form ; as a rule the lumbar portion of the spinal 
column is convex to the left, and the upper dorsal portion is convex 
to the right. It is a matter of dispute whether the lower or upper 
curvature comes first ; whether the first is the primary and the latter 
secondary or compensatory, or the reverse ; as a rule we find both 
curvatures from the start, they probably develop about the same time. 
Tf the faulty position remain unobserved and without treatment, and 
the unfavorable conditions continually increase, the right scapula is 
elevated (the first marked symptom), and as the vertebrae gradually 
rotate the deformity constantly increases, the upper part of the spine 
projects as a gibbosity, the position of the head changes correspond- 
ingly, the thorax is displaced, in short a hump-back is developed. 
From anatomical reasons, which have been carefully traced by H. 
Meyer, the protrusions of the spine posteriorly (cyphosis, from Kvcpog, 
gibbosity) always accompany high grades of curvature, so these de- 
formities are also called " cypho-scolioses." Most old persons with 
humps belong to this class ; patients with caries of the vertebrae 
rarely attain old age ; hence, we only see the so-called Pott's curva- 
ture caused by caries of the vertebrae, in children and very young per- 
sons. The chief cause of scoliosis is weakness of the spinal muscles ; 
as long as feeble children are left entirely to themselves, and can lie 
down, sit, walk, or run, as they wish, and as long as they feel like it, 
scoliosis rarely develops ; but when they are made to occupy certain 
tiresome positions for hours, as in writing, reading, sewing, playing 
the piano, etc., they will seek positions where the muscles for keep- 
ing the body erect are used the least. These positions become cus- 
36 



562 CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 

toniary or habitual. When the children are sitting, even without 
occupation, and politeness forbids their lounging, they support them- 
selves with one hand on the seat ; if they stand, they lean so that the 
body does not need to be supported ; they usually stand on one leg, 
to rest the other. If the curvature of the spinal column has existed 
for months or years, the centre of gravity of the back and head 
changes more rapidly, and the deformity progresses more quickly. 
At first, the intervertebral cartilages are merely compressed on one 
side, then they become relaxed on the other side, grow thicker, and 
the bodies of the vertebrae are compressed more and more, till, from 
being cylindrical, they become conical. This compression sometimes 
also leads to inflammatory new formations, to deposits of osteophytes, 
occasionally even to ossification of the ligaments. 

Genu valgum, or baker's leg, is a deformity of the knee-joint, 
where its shape is such that the leg forms, with the thigh, an obtuse 
angle externally ; if these patients lie on the back, placing the inner 
sides of the knees together, the feet will stand far apart ; to place the 
inner borders of the feet together they must cross the knees. This 
deformity occurs most frequently in young males, who during the 
whole day have to move their bodies and arms while standing, and 
at the same time have to bend their knees ; bakers', locksmiths', and 
cabinet-makers' apprentices are especially predisposed to this affec- 
tion, which is very painful when it is excessive or increasing rapidly. 
The external condyle is strongly compressed, the internal lateral liga- 
ment much stretched, the external lateral ligament contracted, and 
the biceps muscle is shortened and becomes tense. 

Flat-foot, pes planus, is a deformity of the foot, frequently affect- 
ing young girls as well as boys before the age of puberty, when they 
have to stand much. The bones, which form an arch at the inner 
margin of the foot, sink down so that the sole of the foot becomes 
perfectly flat, or even convex downward ; then the outer border of 
the foot is elevated (pes valgus), and the peronei muscles are short- 
ened, their points of insertion being approximated. This deformity 
of the foot is very frequent ; it often follows genu valgum, but oftener 
is independent ; sometimes it comes on very rapidly and with severe 
pain. 

While I consider the above-mentioned continued pressure on 
growing bones as the essential cause of scoliosis, genu valgum, and 
pes planus, still we cannot fail to notice that only a few of the per- 
sons subjected to these injurious influences are affected with the 
above deformities, so that we are naturally led to suppose that besides 
the muscular weakness there must be a special weakness of the os- 
seous system, a softness of the bones ; indeed, I cannot help think- 



PARALYSES OF MUSCLES. 563 

ing that there is a slight amount of rachitis. Lorinsen and some 
other authors claim that the above cause is very prominent in the eti- 
ology of curvature of the spine. Ilueter, Henke, and other authors, 
claim that in all these deformities the articular surfaces grow 
obliquely and uneven ; this certainly has much to do with the in- 
crease of the disease, but can scarcely be recognized as a cause. The 
results of recent investigations render it improbable that (idiopathic) 
contraction and relaxation of the articular ligaments cause these de- 
formities, as I was formerly inclined to believe, although, from the 
displacement and deformity of articular surfaces of the bones, they 
must occur. 



m. DEFORMITIES DUE TO CONTRACTIONS OR PARALYSES OF SINGLE 
MUSCLES OR GROUPS OF MUSCLES. 

This class of cases is very numerous. Acute inflammations in 
muscular substance, or in the immediate vicinity of muscles under 
tense fascias, may cause contractions simply by rendering the stretch- 
ing of the inflamed muscle very painful. It is very common in deep 
abscesses of the neck to find the head inclined to the affected side, so 
that the patient is entirely unable to straighten it ; and this can only 
be done under anaesthesia, when it is readily accomplished. I once 
saw a foot fixed in the position of pes equinus by an abscess in the mus- 
cles of the calf of the leg. Acute inflammation of the psoas muscle 
(psoitis and peri-psoitis) often causes the hip-joint to be flexed at an 
acute angle. "When the pus is evacuated these contractions diminish, 
and often gradually disappear entirely ; but sometimes the cicatrix 
is so large that it continues the contraction, which is afterward re- 
moved with difficulty. 

Secondly, direct nervous irritation from disease of the nervous 
centres may cause permanent contractions ; when these cases start 
from the brain, they offer very little chance for treatment. In caries 
of the spinal column and transfer of the inflammation to the anterior 
roots of the spinal nerves, muscular contractions and paralysis of the 
limbs sometimes occur simultaneously ; in one such case I saw a 
nearly complete cure occur spontaneously. 

Reflex paralysis may also occur. I have seen such cases where 
the thigh, hand, and foot, were affected, particularly in young women ; 
in some cases these contractions were induced by falls on the parts, 
in others by irritation of the genital system (hysterical contractions). 
These cases relax during sleep and anaesthesia. 

Lastly, we come to the most frequent of all of these groups, the 
so-called paralytic contractions, such as occur after partial or total 



564 CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 

paralysis from meningitis and encephalitis, especially in children. 
These contractions occur on one or both sides, chiefly in the lower 
extremities. From its mechanical construction a completely paralyzed 
leg hangs and lies with the foot extended, and turned somewhat in- 
ward ; of this you may convince yourself by examining any cadaver 
which is not rigid. If the foot be not purposely brought out of this 
position, it becomes gradually fixed there, partly by the ligaments on 
the back of the foot, the muscles of the calf, tendo achillis, and super- 
jacent fasciae atrophying, partly by the slower growth of these parts ; 
gradually also the articular surfaces and the form of the bones change 
as a result of unequal pressure, as previously explained, and it becomes 
more difficult and at last impossible to bring the foot into a right-an- 
gled position ; in attempting to effect this the resistance from the 
muscles and tendons is most readily perceived, hence the opinion that 
the gastrocnemius muscle and the tendo achillis were contracted, even 
in cases where it was just as much paralyzed as the other muscles of 
the leg. Then it was thought that only the extensor muscles were 
fully paralyzed, while the antagonists preserved some innervation, so 
that they alone acted on the foot and attained a relative preponder- 
ance. Thus arose the theory of antagonistic contractions taught 
especially by Delpech ; which was sustained chiefly by those cases 
where there was really an unequal distribution of paresis and paraly- 
sis of the different groups of muscles. It was Hueter who first called 
attention to the fact that it was chiefly the continued position as- 
sumed by the paralyzed limb, from its weight, that induced the con- 
tractions, and that these so-called antagonistic contractions were not 
at all muscular actions, but, as in congenital club-foot, were due to 
atrophy and lack of growth. After investigating this view, I must 
entirely agree with it. I had often met cases where the theory of 
antagonistic contractions seemed doubtful ; as in one case where at 
the battle of Sadowa a soldier was shot through the right forearm 
and had the radial nerve torn ; four years subsequently there was to- 
tal paralysis of all the parts supplied by that nerve, but not a sign of 
antagonistic contraction. If we carry our investigations to paralyzed 
limbs, we find that, in cases where the patients sit all day with the leg 
and thigh flexed, contractions take place at the knee and hip, but, if 
the patients with partly paralyzed limbs still have strength enough 
to move about with support, the movements of the joints continue up 
to a certain point. This also you may best see on a cadaver that is 
not rigid ; the foot placed on the ground, with the body resting on it, 
turns outward (pes plano-valgus paralyticus), the knee bends for- 
ward and outward (genu antecurvatum), while at the hip the body 
falls forward till it is supported by the sound leg, crutches, or cane 



SHORTENING OF THE FASCIAE, ETC. 



565 



Thus, from the weight of the body, the limbs assume positions which 
gradually become permanent ( Vblkmann), and in young persons 
have a decided influence on the forms of the articular surfaces. All 
these conditions may be most naturally explained on mechanical prin- 
ciples, while formerly the most complicated theories were based on 
very slight grounds, when any explanation was attempted. 



IV. LIMITATIONS OF MOTION IN JOINTS CAUSED BY SHORTENING OF 
FASCLE AND LIGAMENTS. 

Any long-continued fixed position of a joint, even if not due to 
the above-described diseases of muscles and nerves, may lead to short- 
ening of the fasciae. A man who kept his left leg and thigh 
flexed for a year and a half, on account of suppuration of the inguinal 
glands, was brought to our clinic after the bubo had healed, because 
he could not extend the leg. This is particularly true of the fascia 
lata, which from a few months of quiet may become so rigid that it is 
sometimes impossible to extend it again. After coxitis has run its 

Fig. 109. 




Contraction of the fascia lata from coxitis, after Froriep. 



course, when the joint has become perfectly healthy, this contraction 
of the fascia may prove a permanent obstruction to complete exten- 
sion, so that such patients may occasionally limp for life ; which is 
another important reason for paying special attention to the position 
of the limbs in inflammation of the joints. 



566 



CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 



V. DEFORMITIES CAUSED BY CICATRICEa 

"We have already spoken frequently of the contraction of cica- 
trices ; it results from the inflammatory new formation in the wound 
gradually giving" off water, as the original gelatinous formation by 
degrees atrophies to dry connective tissue, and contracts like any body 
that is drying up. The larger the surface of the cicatrix, the stronger 



Fig. 110, 



Fig. Ill, 





Cicatricial contractions after burns. 



will be the contraction in all directions ; all wounds with extensive 
loss of skin will be followed by extensive cicatricial contraction, and, 
as this is generally greatest after burns, cicatrices from this cause are 
usually the ones that contract most. Of course it depends greatly on 
the position of the cicatrix whether it shall produce injurious results, 
deformities or distortions. Cicatrices on the flexor side of the joint, 
when they extend far longitudinally, may prevent full extension of 
the limb. Extensive cicatrices in the neck induce distortion and 
fixation of the head to the injured side ; those on the cheek may dis- 
tort the mouth or lower eyelid ; on the back of the hand or foot, or 
about the finger-joints, they may render the finger immovable, or par- 
tially so. 

But cicatrices of the deeper parts, as of the muscles and tendons. 



TREATMENT OF CONTRACTIONS. 567 

may, of course, also cause deformities ; as necrosis readily follows in 
jury of a tendon, and cicatricial tissue replaces the tendon, such a 
part as a finger, when injured, becomes crooked and stiff. 



Although, in what has just been said, we have spoken chiefly of 
the etiology of deformities, still the diagnosis is included there ; and 
it is unnecessary to pursue this point further. Of course the prog- 
nosis depends entirely on the possibility of removing the causes, and 
the treatment also varies greatly with the latter. 

To remove contractions, the most natural thing is to stretch the 
parts ; we may try this by having the contracted limb stretched a few 
times daily. But this so-called manipulation, which is very effica- 
cious, requires much strength and patience ; hence it seems better to 
make this extension by the regular action of a machine. The ex- 
tending machines now used depend on the combined action of the 
screw and cog-wheel, a mechanism that has been employed in surgical 
instruments from the most ancient times ; the machines may be vari- 
ously constructed, but must be light, firm, and well padded ; they 
should never press too hard, and be made to retain any position ; such 
machines are most readily made for the knee and elbow ; in the shoul- 
der and hip it is difficult to fix the scapula and pelvis. Extension 
may be made under anaesthetics, to hasten the progress ; but then 
avoid using too much force, and especially bear in mind that cica- 
tricially-contracted muscles are less distensible than normal ones, and 
can only be stretched gradually. Mechanical extension can scarcely 
be applied to those muscular contractions depending on neuroses, or, 
at most, it can only be used as an adjuvant ; the chief treatment must 
be directed to the nervous affection that has caused the muscular 
contraction. Not unfrequently these contractions entirely disappear 
under chloroform, especially when of a reflex character, in the same 
way that they subside spontaneously in acute articular inflammations, 
as soon as the patient is narcotized ; the flexed knee, for instance, 
may then be extended without the least force. According to Memak, 
many contractions disappear under the use of the constant current of 
electricity ; as many excellent men are now engaged studying the 
constant current, it is to be hoped that the mystery, which has until 
lately shrouded this subject, may disappear before clear criticism. 
Treatment by apparatus (orthopedy) is particularly used in contrac 
tions of ligaments and fasciae. Contractions from cicatrices may be 



568 CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 

improved, but rarely entirely cured, by stretching the cicatrix; a 
more potent remedy here is continued pressure, made by adhesive 
plaster, bandages, or compresses, applied to suit each case. The 
atrophy of the cicatrix, which occurs spontaneously, in the course 
of years is much promoted by this treatment. Distention is com- 
bined with compression in the treatment of ring-shaped cicatricial 
contractions of canals, so-called strictures, such as occur chiefly in 
the urethra and oesophagus, by the introduction of elastic sounds 
(called bougies because they were formerly made of wax) of gradu- 
ally-increasing thickness. 

The orthopedic treatment previously mentioned does not always 
succeed, or at least is often very slow, hence even in the middle ages 
the tendons of the contracted muscles or the muscles themselves were 
divided ; this operation is called " tenotomy," or " myotomy ; " the 
former is far the more frequent. Formerly the operation was done by 
simply incising the skin down to the tendon, then dividing the latter, 
and letting the wound heal by suppuration ; the results were not very 
brilliant : the suppuration was sometimes very extensive, thick cica- 
trices formed, which could only be slowly stretched. This operation 
was first made really serviceable by Stromeyer, who taught us to 
divide tendons subcutaneously, a method which Dieffenbach intro- 
duced extensively into practice, and which is now exclusively used. 
I shall first describe this operation briefly before passing to its results. 
Let us take, as an illustration, tenotomy of the tendo Achillis, which 
is the most frequent. For this operation you may best employ Dieffen- 
baches tenotome, a slightly-curved, pointed, narrow knife. The pa- 
tient lies on the belly, an assistant holds his leg firmly at the calf; 
with your left hand you seize the club-foot ; with your right hand 
introduce the knife, flatwise, by the side of the tendon under the skin, 
and over the tendon, till you have passed beyond the tendon, without, 
however, perforating the skin a second time ; now turn the edge of 
the knife toward the tendon and divide the latter — when so doing you 
will hear a crackling sound ; as the division is completed, you will 
feel with the left hand that the foot is more movable ; you now care- 
fully draw out the knife. Only the point of entrance of the knife is 
visible externally, the tendon has been divided subcutaneously. This 
method of subcutaneous tenotomy from loithout inward is easier for 
beginners, because in it there is no danger of dividing the skin more 
than is necessary. Tenotomy from within outward is more elegant 
and better suited for some cases. The foot is held as above, and the 
knife is entered the same way, but it is then passed under the tendon 
and the cutting edge turned toward the tendon; the thumb of the 



TENOTOMY. 569 

right hand should be placed over the point of the knife to feel it and 
prevent passing it through the skin ; we then press on the knife and 
draw it from within outward through the tendon ; being careful not to 
let it cut through the skin when the jerk occurs that accompanies the 
completion of the division. This method seems more difficult than it 
is, but, like any operation, it requires practice on the cadaver. When 
the tenotomy is completed, there is usually but little bleeding from 
the puncture, though sometimes there maybe considerable, as in some 
persons a tolerably large branch of the posterior tibial artery runs 
alongside of the tendon, and is divided with it. If the bleeding be 
slight, a piece of ichthyocolla-plaster may be placed over the puncture, 
and rendered firmer by collodium ; if the haemorrhage be more profuse, 
the puncture should be covered with a small compress, and the foot 
bandaged as high as the calf; the bleeding then ceases. This dressing 
should be replaced by plaster after twenty-four hours. The healing 
is almost always by first intention ; the puncture is closed in three or 
four days. But there may be suppuration ; then the wounded part 
grows red, swollen, sensitive ; blood mixed with pus flows from the 
wound, an abscess often forms on the opposite side ; this must -be 
opened, and, although this suppuration is not dangerous to life, it 
may continue two or three weeks, and much impair the results of the 
operation, for it is a long time before the resulting thick cicatrix is 
suited for extension. Immediately after the tenotomy, at the point 
of division you may feel a hollow, as the muscle contracts after 
division of the tendon ; this hollow disappears in the course of 
twenty-four hours, and for a few days it is even replaced by a swell- 
ing ; the latter gradually subsides, and in fourteen days at most, after 
a • normally-healed tenotomy, the tendon appears perfectly restored. 
The course of this healing has been carefully studied experimentally ; 
formerly it was supposed there was something very peculiar about it ; 
I have often made these experiments on animals, and find that healing 
takes place as it usually does, and most resembles that process in 
nerves and bones. When the tendon is divided, and the muscle con- 
tracts, there would be an empty space at the point of division if the 
external atmospheric pressure did not at once press the surrounding cel- 
lular tissue into the space between the ends of the tendon ; the space 
is thus filled up ; as in any wound, this tissue is infiltrated with plas- 
tic matter and serum, and becomes very vascular ; the cellular tissue 
around the ends of the tendon is metamorphosed in the same way, and 
the latter are surrounded and united by the inflammatory new formation 
developed from the adjacent cellular tissue, just as the fragments 
of bone are by the external callus (which, however, here presses 



570 



CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 



Fig. 112. 



between the ends of the tendons also ; an internal 
callus cannot develop in tendons, as they have no 
medullary cavity). In this stage (about the fourth 
day), the picture is somewhat as in Fig. 112. 

This provisional union soon becomes firm, as the 
inflammatory new formation is metamorphosed to 
connective tissue ; meantime, some neoplastic tissue 
has developed in the stumps of the tendon, which 
combines with the intermediate substance. The 
entire newly-formed intermediate mass gradually 
contracts strongly, becomes very firm, so that it as- 
sumes exactly the character of tendinous tissue ; the 
tendon is thus entirely regenerated. It is true this 
does not always go on as rapidly as we have here 
described, but (as also occurs in fractures) is not 
unfrequently interfered with by a large extravasa- 
tion of blood between the ends of the tendon ; this 
is enclosed by the inflammatory new formation, be- 
comes only partially organized, but must be mostly 
reabsorbed before there can be complete regenera- 

Di SS y °divided C ten- tion of the tendon - Extensive extravasations of blood 
don, on the fourth mav interfere with the regular course of healing, 
not only by their size and the time required for their 
absorption, but oy occasionally putrefying and suppurating. The oper- 
ation and course of healing in myotomy are about the same as have 
just been described. 

You have just heard that the tendon is entirely regenerated, and 
the cicatricial intermediate substance contracts strongly, that is, it 
shortens, and you will justly wonder why, knowing these facts, the 
operation is still done, as the tendon is not thereby much elongated. 
To this I answer that tenotomy of itself is of no use, or, at least, does 
little good, but that the tendinous cicatrix may be much more readily 
stretched than the tendon of the contracted muscle or the muscle it- 
self; tenotomy only proves useful from the orthopedic after-treatment ; 
it greatly aids the cure, and often it alone renders it possible, when 
the contracted muscles, fasciae, or ligaments, resist all efforts at exten- 
sion. Hence we should not await complete cicatricial contraction of 
the divided tendon, but must stretch the young cicatrix ; the orthope- 
dic treatment may begin ten or twelve days after division of the ten- 
don in club-foot, either by extension, manipulations, and apparatus, or 
by straightening the foot and applying a plaster dressing. Favorable 
results were first rendered possible by subcutaneous tenotomy ; then 
the healing goes on rapidly, and a distensible cicatrix forms; if the 



TENOTOMY. 571 

wound suppurates a long time, and the skin is also affected, the brittle 
cicatrix probably may not become distensible for six or eight weeks, 
for sooner it might tear and begin to suppurate again. Of course 
every club-foot, especially of the lower grades, does not require tenot- 
omy ; but it is just as certain that in high grades of this deformity 
tenotomy favors the cure. From what has been said, you will see 
that the indications for tenotomy are often the same as those for 
orthopedic treatment ; this is not absolutely the case ; the indications 
for tenotomy are sometimes more limited, sometimes more general. 
We may divide any tense tendon subcutaneously ; but whether this 
will do any good is another question. We cannot here speak of all 
possible cases, but I will mention the tendons most frequently divided : 
in the neck, the two portions of the sterno-cleido-mastoid muscle, at 
their insertions on the clavicle and sternum ; tenotomy is rarely done 
in the arm ; I warn you against this operation in the fingers and toes ; 
all tendons with fully-developed sheaths are unsuited for tenotomy ; 
from anatomical reasons, that you may readily perceive, healing would 
not occur so simply as in tendons surrounded by loose cellular tissue ; 
there is usually suppuration, frequently with bad results, or else the 
ends of the tendon remain ununited. In the thigh, after coxitis, the 
contracted adductor muscle may be divided at its point of origin, if 
its contraction cannot be overcome during anaesthesia ; the same is 
true of the biceps femoris, semitendinosus and semimembranosus, 
which are to be divided close to their points of insertion into the 
fibula and tibia. . In the foot, the tendo Achillis is most frequently 
divided, as are also occasionally the tendons of the anterior and poste- 
rior tibial and peroneal muscles, although it seems to me that this 
injures the subsequent mobility of the foot. In straightening anchy- 
loses, tenotomy was formerly very often resorted to ; but for this pur- 
pose it may be entirely dispensed with. In anchylosis of the knee- 
joint, for instance, if the above-named muscles be not united to a cic- 
atrix, they may be gradually stretched during anaesthesia, that is, if 
they be still muscles and not strings of pure connective tissue, as is 
rarely the case. I shall not here speak of tenotomy of the ocular 
muscles, the operation of strabismus, as this is treated of in ophthal- 
mology. Sometimes, also, we may be obliged to divide tendons in 
antagonistic contractions, for the purpose of rendering the contracted 
muscles inactive for a time, and subsequently elongating their tendons 
by extension, to give the paretic antagonist more play and less work ; 
the latter are then opposed by no force, or, at least, by a weaker one, 
so that equilibrium is restored. Of course, this is only to be done 
for muscles whose antagonists are not entirely paralyzed, but only 
paretic; in perfect paralysis, tenotomy of the contracted muscles 



572 CONGENITAL DEFORMITIES OF THE JOINTS, ETC. 

would have no effect. The revivifying action of tenotomy is occasion- 
ally spoken of; it is to the above cases that this expression refers; 
indeed, in antagonistic contractions the action of tenotomy is some- 
times astonishing. 

The subcutaneous division offascice is not much done ; the cords 
of the fascia lata, which form when the thigh is kept flexed, are often 
divided with benefit, as it is difficult to stretch them ; the fascia plan- 
taris may also be occasionally divided with benefit, when it is tense, 
in club-foot. Division of the fascia fails in the cases where we might 
use it with most benefit, that is, in contraction of the palmar fascia. 
From Dupuytrerts description of the results of this operation, in spite 
of the warning of my former preceptor, I was once led into per- 
forming it ; but it was followed by such extensive suppuration that I 
was glad when this finally ceased. In spite of all orthopedic after- 
treatment, the hand finally remained as it had been ; some slight im- 
provement soon disappeared again, and I believe that this affection, 
in its higher grades at least, is incurable. 

Division of ligaments is rare ; but in club-foot I have often divided 
the small ligaments of the ankle-bones, if they were tense ; and, in 
spite of the fact • that I must certainly have frequently opened the 
small joints subcutaneously in so doing, I never saw any bad results. 
JB. von Lang enbeck introduced division of the external lateral ligament 
of the knee in genu valgum ; in this the knee-joint is always tempo- 
rarily opened. This operation is only proper in the highest grade of 
the affection, but greatly aids the treatment ; I had not previously 
seen it, or even thought much about it, fearing that it might be fol- 
lowed by suppuration of the knee-joint ; a few years since, in one 
case, I did the operation on both knees of a young man who had ex- 
cessive genu valgum ; the wound healed without any inflammation of 
the knee-joint, and the orthopedic treatment was very quickly con- 
cluded. The patient went out of the hospital with his legs perfectly 
straight. On the whole, the operation is rarely indicated. So far as 
I know, no other ligaments are divided. 

It was natural to think of dividing contracting cicatrices also, so 
as to stretch the new cicatrix ; but would it not be wiser not to let 
the cicatricial contraction come to such a point as to impair function ? 
Would it not be best, even during the healing of a large wound — in 
the bend of the elbow, for instance — to keep the arm extended, so 
that it should not be contracted by the cicatrix ? The idea is a good 
one ; but the result rarely corresponds to such a tedious treatment, 
for, in the first place, such wounds, in which there can be no cicatricial 
contraction, heal with great difficult}? - , and, when they are finally healed 
and the limb is set free, contraction nevertheless occurs. I well re- 



CONTRACTED MUSCLES. 573 

member a child with such a wound in the bend of the elbow, from a 
burn, which, as assistant in the Berlin clinic, I had to dress daily. The 
arm was kept extended on a splint, and took six months to heal ; 
finally, the child was discharged, with the arm perfectly movable and 
the wound healed, and I was very proud of the cure. Two months 
later I saw the child, with the cicatrix entirely contracted ; the arm 
was at an acute angle, and almost immovable. Subsequently I lost 
sight of the patient, and do not know what was the final result ; but 
I clearly saw that I had worried myself and the child for months in 
vain. Several similar cases have radically cured me of the idea that 
we can, in such cases, do much by orthopedic treatment during the 
cicatrization of the wound. I advise you to let the wounds heal as 
they will ; large wounds, from burns in children, will even thus give 
you enough trouble, as they always heal with difficulty, and readily 
assume an ulcerative character. In the course of months, often not 
for years, as its vessels are obliterated and its tissue becomes more 
like subcutaneous tissue, the cicatrix loses its rigidity, becomes more 
distensible, tougher, more elastic; hence, with time, mobility in- 
creases, in case it has been impaired by the cicatrix. You have al- 
ready been told how you may aid this atrophy of the cicatrix by com- 
pression and distention. When the cicatrix has finally been reduced 
to the smallest size, you may occasionally, with advantage, excise 
the whole or part of it, at intervals, always being careful to obtain 
healing by the first intention, so that, in place of the thick, scarcely- 
distensible cicatricial string, you may have a fine linear cutaneous 
cicatrix, which may be stretched more readily than the old cicatrix ; 
but if you have suppuration and gaping of the wound after these 
operations, the result is very doubtful (as, under the same circum- 
stances, in tenotomy) ; there again forms a broad, granulating, slowly- 
healing wound, and a cicatrix as broad, long, and firm as the previous 
one. Hence you can only advantageously excise contracted, string- 
like, thin cicatrices. In removing complete, broad cicatrices, such as 
occur in the neck after burns, excision is not enough ; a portion of 
distensible skin from the vicinity must be made to grow in the place 
of the cicatrix. This may be done by sliding a piece of neighboring 
skin, or by transplanting a flap of skin, according to the rules of plas- 
tic surgery, which I shall not enter into here. 

We have now to speak of the treatment of distortions due to an- 
tagonistic muscular contractions ; I have already told you that tenot- 
omy may be useful in these cases also, but it is only an adjuvant to 
the treatment; the essential point is the removal of the paralysis. 
The curability of these contractions, and of the deformities they cause, 
will depend on what we can do for the paralysis. Here opens the 



574 CONGENITAL DEFORMITIES . OF THE JOINTS, ETC. 

wide field of neuropathology, with which you will become better ac- 
quainted in the lectures on medicine, and in the medical clinic. There 
are many cases where you would at the outset give up any treatment of 
the paralysis ; in tumors of the brain, apoplexies, chronic encephalitis, 
traumatic injuries of the spinal medulla, extensive injuries of nerves, 
etc., treatment will do little good. Other cases of spinal disease with 
paresis of the lower limbs, especially in children, sometimes give a 
relatively good prognosis. On the one hand, treatment with cod-liver 
oil and iron, malt or salt baths, and especially time, may act very ad- 
vantageously in removing the changes in the spinal medulla, of which 
we unfortunately know but little ; on the other hand, irritations may 
be applied to the muscles themselves, that may revivify them; we 
may expect relief in those cases especially where there is no complete 
paralysis or paraplegia, but only paresis of certain groups of muscles. 
Here two external remedies are the most useful: 1. Gymnastic treat- 
ment / 2. ^Electricity. The former consists in awakening the slumber- 
ing, slightly-developed contractile power by concentrating the will on 
the paretic muscles. Certain movements are made regularly at cer- 
tain times ; this may be well done by the " Swedish movement-cure " 
that has been recently introduced: this consists in requiring the 
patient to make movements with certain muscles, while the gymnast 
offers a slight opposition. For instance, I hold your arm extended;' 
you now bend it, while I oppose the movement by gentle pressure ; of 
course, the proper movements must be determined for each individual 
case. Of late, this method of gymnastics has become quite popular, 
and proved useful ; evidently it, like all gymnastics, is useless in com- 
plete paralysis. 

Our second remedy is electricity; of late great advances have been 
made in its use. The apparatus employed has been greatly simplified, 
rendered more transportable, and so adjusted that the current can be 
strengthened or weakened at will. Moreover, the methods in which elec- 
tricity is applied are greatly improved ; formerly one or several groups 
of muscles of a limb were electrified, by applying the poles first on 
one place then another; now we understand electrifying the individual 
muscles ; the French physician Duchenne de Boulogne has done great 
service in this matter. The points at which the pole or poles should be 
applied to induce contractions in the different muscles were first found 
empirically by Duchenne ; subsequently Hemak discovered that, as a 
rule, it was at the point where the largest motor nerve entered the 
muscle. Of late, Ziemssen has been most successful in electro-thera- 
peutics ; his book is characterized by practical utility and scientific 
importance, and above all by its trustworthiness. The treatment is 
so carried out that usually one or two sittings are had daily, during 



CONTRACTED MUSCLES. 575 

which first one, then another, muscle is methodically electrified ; this 
may be continued half or three-quarters of an hour, but not too long, 
for fear of destroying the weak nervous activity by too great irrita- 
tion. Much harm might be done by excessive electrization ; a physi- 
cian should always conduct the treatment, and give very positive di 
recti ons about the duration of the sitting, and strength of the current. 
Usually we very soon see how much the muscles contract to the elec- 
trical irritation when they perhaps cannot be moved spontaneously ; 
we should not give up even if we do not obtain any twitchings at the 
first sitting ; occasionally these only appear after a time, when the 
electricity has had some effect. 

Of late, JBarwell has successfully employed a very ingenious meth- 
od for removing contractions; he makes continued traction in the 
direction in which the muscles fail to act ; for instance, in club-foot, a 
stout india-rubber band is fastened to the outer border of the foot, 
and the inner side of the tibia close below the knee ; this acts contin- 
uously as an " artificial muscle." This seems to me rational, and it 
should be tried extensively. I have used this method in several cases, 
with very quick result; Xitclce and VblJcmann have also stated 
recently that they have attained good results by this treatment. 

In pareses, movement of a few muscles occasionally suffices to 
enable the patient to walk, if a certain firmness which the muscles fail 
to supply is given to the limb by some sort of a splint. These splints 
are not always to be regarded as a last resort, but they may aid the 
treatment by enabling the patient to walk alone with the aid of sticks. 
But the movements of walking, made by the paretic muscles, have an 
excellent gymnastic effect ; although artificially supported, the patient 
in this way uses his muscles, while, if he were continually lying or sit- 
ting, the muscles. would remain entirely inactive, and atrophy more 
and more. Machines are also serviceable in keeping the legs ex- 
tended and the feet at the proper angle, thus preventing contractions. 

Gymnastics, electricity, artificial muscles, and splint apparatuses, 
combined with proper internal treatment, especially suitable water- 
cure, may do a great deal for these patients ; and, although many of 
them are incurable, some are curable, and others may be greatly im- 
proved. 



CHAPTER XIX. 
VARICES AND ANEURISMS. 



LECTURE XLIII. 

Varices : Various Forms, Causes, Various Localities where they occur. — Diagnosis. — 
Vein-stones, Varicose Lymphatic Vessels, Lymphorrhoea. — Treatment.— Aneu- 
risms: Inflammation of Arteries. — Aneurysma Cirsoideum. — Atheroma. — Various 
Forms of Aneurism.— Their Subsequent Changes.— Symptoms, Eesults, Etiology, 
Diagnosis. — Treatment: Compression, Ligation, Injection of Liquor Ferri, Extir- 
pation. 

By varices we mean distentions of veins ; these may have various 
forms, and usually affect both the diameter and length of the vessel. 
Elongation is only possible when the vessel bends laterally, and takes 
a tortuous course, as also occurs in inflammation of the smaller vessels. 
In some cases the elongation is less marked, and the diameter of the 
canal is not regular, but the vessel is distended in a spindle or sack- 
like shape at different points, especially where the valves are. Most 
frequently the large veins of the subcutaneous cellular tissue are thus 
affected ; sometimes chiefly the deep muscular veins, often both are 
alike affected. But there are also varicosities in .the smallest veins of 
the cutis, which are scarcely visible to the naked eye, these are often 
the only ones affected; this gives an even, light-blue nodular appear- 
ance to the skin. As a result of this distention of the veins, which 
occurs very gradually, more serum than usual escapes from the capil- 
lary vessels, as the lateral pressure in them is greatly increased by 
the distention of the walls of the veins, and the consequent insuffi- 
ciency of the valves. The thinning of the walls of the vessels, and 
the transuded excess of nutrient material, may be gradually followed 
by escape of wandering cells, and their organization to new tissue ; 
thus we have a serous, then cellular infiltration, and thickening of the 
tissue traversed by the varices; red blood-cells may also escape 
through the capillary walls ( Cohnheim). We have already explained 



VARICOSE VEINS. 



577 



Fig. 113. 



(Lecture XXIX.) how, by a further advance of this process, the tissue 
is more and more changed, and chronic inflammation and ulceration in- 
duced. In this way are developed not only ulcer- 
ations but also some other forms of chronic cuta- 
neous inflammations, especially a chronic eruption 
of vesicles, " eczema " of the leg. 

Now we must take up the question, What is 
the cause of varices? It is probable that the 
cause is an obstruction to the return of the venous 
blood, a pressure, compression, or narrowing of 
the calibre of the vessel in some way. But the 
obstruction cannot be of sudden origin, for this 
usually causes oedema ; the same is true of liga- 
tion of a large venous trunk and rapidly-appear- 
ing thromboses. The pressure must then affect 
the vein gradually. Still, even this is not enough ; 
often a gradually-increasing pressure does not 
cause varicose veins, but free collateral modes of 
escape form, so that there is no effect, or only a 
slight, indurated oedema. There must be a coin- 
cident tendency to dilatation of the vessels, a cer- 
tain laxity or distensibility of. the walls of the 
veins. 33 

Anatomical examination of varicose veins 
shows that the walls are absolutely thickened by 
deposits of connective tissue between the muscle- 
cells, but the latter do not seem increased, and, as 
the calibre of the vessel is six or eight times the normal size, the}' must 
prove insufficient to urge the blood onward, the more so as the valves 
do not grow as the dilatation goes on, and consequently soon prove in- 
sufficient. Up to the present time we have had no detailed histological 
investigations about the formation of varices, and especially about 
the relation of this disease to aneurism. In many cases the dispo- 
sition to varices may be regarded as individual, in others it is in- 
herited ; diseases of the vessels are not unfrequently hereditary, those 
of the arteries, as well as of the veins and of the capillaries, by whose 
morbid dilatation the so-called mother's marks are caused, whose 
transmission by inheritance is known even to the laity. Hence, we 
can only regard the cause of varices, which we are about to mention, 
as exciting causes acting on an existing predisposition. The disease 
is more frequent in women than in men ; the chief cause is said to be 
repeated pregnancies : the uterus, gradually enlarging, presses on the 
common iliac veins, and later on the vena cava, and occasionally this 
37 




Varices in the part sup- 
plied by the great sa- 
phena vein. 



578 VARICES AND ANEURISMS. 

even induces cedema of the feet. Often there are varices in all the 
parts supplied by the saphenous vein ; again, in those supplied by the 
pudic, as in the labia majora, It is far more difficult to find the causes 
of the more rarely-occurring varices in man. Large collections of 
fasces may, by pressure on the abdominal veins, prove an exciting 
cause of varices, but this is rarely seen. In many men with varices 
you will find disproportionately long lower limbs, especially long be- 
low the knee ; in some cases this may also favor congestions in the 
veins. Possibly, also, the collection of hard fat, or else shrinkage in 
the falciform process of the fascia lata, may cause congestion in the 
saphenous vein, as the latter sinks into the femoral at this point. So 
far as I know, there are no anatomical investigations on this point. 
The obstruction to the flow of blood need not always be directly in 
the territory of the dilated veins : for instance, gradual narrowing and 
final obliteration of the femoral vein, below the opening of the sa- 
phena, might very readily cause enormous distention of the branches of 
the latter by collateral circulation. Varices occur at some other parts 
of the body, especially at the lower part of the rectum and in the 
spermatic cord. Varices of the hemorrhoidal veins in the lower part 
of the rectum cause haemorrhoids, which, as is well known, occur 
chiefly among persons who lead a sedentary life. The disease is very 
rare in other parts of the body ; it occasionally occurs in the head, 
usually without known cause, it may form after an injury, if this be 
followed by union of the walls of the arteries and veins and passage 
of arterial blood into the veins ; this would be a varix aneurysmaticus, 
of which we spoke in the second chapter. In the pathological ana- 
tomical atlas of Cruveilhier you find given as a great rarity a picture 
of large varices of the abdominal veins ; there is a similar preparation 
in the pathological museum at Vienna. 

The diagnosis of varices is not difficult when the cutaneous veins 
are affected ; those of the deep muscular veins can rarely be diag- 
nosed with certainty ; in the leg and thigh the whole course of the 
tortuous veins is so evident through the skin that they may be readily 
recognized, but in other cases we see only a few light-blue, fluctuat- 
ing, compressible nodules; these chiefly correspond to the sac-like 
dilatations of the veins, and to the points where the valves are. Here 
we occasionally find hard, round bodies, phlebolites or vein-stones / on 
examination, these prove to be nodules in layers, at first consisting 
of fibrine; they may subsequently calcify entirely, so as to assume the 
appearance of small peas. In the great majority of cases, varices of 
the lower extremities cause no difficulty, except, perhaps, a feeling 
of tension and heaviness in the limbs after long standing or walking. 
But in other cases there are occasionally thrombi in single venous dila 



TREATMENT OF VARICES. 579 

tations ; inflammation of the wall of the vein and surrounding cellular 
tissue follows, and, although, under early treatment, the inflammation 
usually terminates in resolution, suppuration or abscess may eventu- 
ally develop. The treatment is the same as has been already given 
for traumatic thrombus and phlebitis. Another danger that may 
arise from varix is its rupture, a very rare occurrence ; if the patient 
be kept quiet, the bleeding may be readily checked by compression, 
and there is no danger if medical aid be at hand. A varicose ulcer, 
in the strict meaning, may form from such a ruptured varix, but this 
is rare, for the wound usually heals quickly. If the skin and subcu- 
taneous tissue of the leg be greatly indurated, and if this induration 
has also affected the adventitia of the cutaneous veins, they lie im- 
movable, and, in the firm, leathery, rigid skin, they feel like half canals 
or gutters. I call your attention to this, as otherwise in such cases, 
from the induration of the skin, you might entirely overlook the varices. 
The treatment of varices is very unsatisfactory, as we know no 
way of removing the disposition to this disease of the veins. Nor 
can we usually control the causes of the pressure; so we may really 
conclude that varices are not curable, i. e., we have no remedy for 
restoring the morbidly-dilated veins to their normal size. For some 
cases we must say that, physiologically considered, the formation of 
varices is Nature's mode of equalizing abnormal pressure in the ves- 
sels, and that we may not try to remove the varic.es till we can get 
rid of their causes, for, if we removed one or more of these morbid 
strings, others would form in their place. For this reason I reject all 
operations which aim at removing one or more varicose nodules from 
the leg. If you bear in mind that any operation on the veins may 
prove dangerous to life by complication with thrombosis or embolism, 
you will agree with me in considering the operation for varices en- 
tirely uncalled for. Nevertheless, these operations are often done in 
France, and not unfrequently prove fatal ; there are many methods 
of operation, about which we shall say a few words. The oldest 
method, which was practised by the Greeks, consists in exposing the 
varicose veins, and either cutting or tearing them out. Later, the hot 
iron was applied to induce coagulation of blood in the veins, which 
resulted in obliteration of the vessels. We may also inject liquor 
ferri sesquichlorati with a small syringe having a needle-shaped noz- 
zle, as you know this quickly causes coagulation of the blood. After 
this came the ligature of the veins, especially the subcutaneous liga- 
ture after Hicord, and the subcutaneous rolling-up, the enroulement 
of Vidal) little operations that I shall show you in the course on op- 
erations ; these are very ingenious methods, but I am sorry to say 
they do not succeed, and are not free from danger. 



580 VARICES AND ANEURISMS. 

But shall we do nothing for varices ? Yes, we should try to keep 
them within certain bounds, and thus prevent or reduce to a minimum 
their bad effects. For this purpose there is only one remedy, con- 
tinued compression, which, however, must only be used in such a de- 
gree as is bearable to the patient. We use two different mechanical 
modes of compression in these cases, the laced stocking and regular 
bandaging. The laced stocking consists either of a carefully-made, 
close-fitting leather stocking, split at one side, and laced up, like cor- 
sets, till it is tight enough, or else of a tissue of rubber thread, spun 
over with silk or cotton, of the same stuff that most suspenders are 
made of. These laced stockings, which must be very carefully made, 
and worn continually, are unfortunately quite expensive, and, as they 
cannot be washed, must often be replaced, so that they are only prac- 
tically useful for persons of means. In most cases a carefully-applied 
roller-bandage suffices. For this purpose, you may best take a cotton 
bandage two or three fingers' breadths wide, soaked in good book- 
binder's paste, and, excepting the heel, bandage the whole foot and 
leg ; with care, such a bandage may be worn five or six weeks, and 
even if the skin be considerably infiltrated, it may prevent the forma- 
tion of ulcers by obstructing the further development of varices. 



It is some time since we spoke of traumatic aneurism, but you 
will remember that we mentioned it under punctured wounds (page 
135), and that I then told you an aneurism was a cavity, a sac, which 
directly or indirectly communicated with an artery; you already know 
that such sacs may develop from injuries of the artery by puncture, 
subcutaneous rupture, or contusion. But noAV we do not mean to 
speak of these traumatic, so-called false aneurisms, but of aneurysma 
verum, which develops gradually from disease of the wall of the ar- 
tery. To explain to you clearly how this occurs, it will be best to 
start from the anatomical conditions. At present, you know but little 
of the diseases of arteries ; the only ones that have been mentioned 
so far are thrombosis after injury, the development of collateral circu- 
lation, and atheroma, which we hastily spoke of when treating of 
6enile gangrene. And these comprise almost the whole list, only that 
so far we have taken merely a one-sided view of atheromatous dis- 
ease. Of the different parts of arteries the tunica muscularis and 
intima are most frequently diseased, and they seem to be affected 
primarily. The tunica media is composed of muscle-cells ana some 
connective tissue; the tunica intima consists of non-vascular, elastic 
lamella?, fenestrated membranes, and very thin endothelium. It may 
be readily shown that, after injury of an artery, its walls swell, and 



CIRSOID ANEURISMS. 581 

remain thickened for a time ; the plastic infiltration of the walls may 
lead to suppuration, and small foci of matter may form in them, 
though this is seen more rarely in arteries than in veins. With these 
processes there is a relaxation of the membranes, the intima may be 
detached from the media more readily than usual, the latter is soft- 
ened, the muscle-cells may in part disintegrate, and, as a result of 
this diminished resistance, there may be a dilatation of the artery. 
Such acute inflammations with plastic new formations and partial 
softening may doubtless occur spontaneously, and, although we have 
no special observations on this point, still, from analogy with other 
tissues, there is no doubt that a spontaneous, idiopathic, acute, and 
subacute inflammation of the arteries may run its course in this way, 
and probably occurs with acute inflammations of other tissues. At 
all events, these acute spontaneous inflammations of arteries are very 
rare ; the chronic forms are far more frequent. One form of« aneu- 
rism alone possibly depends on a more subacute inflammation of the 
artery, with diminished resistance of its walls ; this is a?ieurysma 
cirsoideum, or aneurysma per anastomosing also called aneurysma 
racemosum. This form of arterial dilatation is totally distinct 
fronl the aneurisms to be hereafter mentioned ; in them there is not 
circumscribed dilatation of one part of an artery, but dilatation of a 
large number of arteries lying close together, which are, moreover, 
very tortuous, a sign that they have also increased in length. Cirsoid 
aneurism is, then, a convolution of dilated and elongated arteries. 
For these changes to occur, there must be a considerable new forma- 
tion in the wall of the artery, longitudinally, as well as in the circum- 
ference; the dilatation is possibly due to atrophy of the muscular 
coat ; usually (without, however, being able to prove it) paralysis of 
the walls of the arteries is assumed to be the exciting cause of this 
variety of aneurism ; still, although paralysis might explain a mod- 
erate dilatation of the artery, we have nothing to explain the paral- 
ysis, and this would not render any more comprehensible the elonga- 
tion of the artery, which can only depend on a new formation of the 
elements of the wall. As already stated, I think that this variety of 
arterial dilatation, which closely resembles inflammatory dilatation 
and looping of vessels, must be referred to an inflammatory change 
in the artery, and not to chronic inflammation with atheroma, to be 
hereafter described, but to a more subacute, diffuse inflammation. 
This view is supported by various etiological factors ; these aneu- 
risms not unfrequently develop after blows or other injuries ; they are 
most frequent at points where numerous small arteries anastomose, as 
in the scalp, over the occiput, vertex, and temples ; this variety of 
aneurism might be regarded as an excessively-developed collateral 



582 



VARICES AND ANEUKISMS. 



circulation ; the collateral arteries, besides dilating, become tortuous : 
the process is evidently the same in both cases. We have also to 
mention that these aneurisms are particularly apt to develop in young 
persons, in whom the chronic diseases leading to other aneurisms are 



Fig. 114. 




Cirsoid aneurism of the scalp in an old woman ; a small tumor was said to have existed al 
birth, and to have developed gradually to this size. After Breschet.. 



rare. The diagnosis of cirsoid aneurism is very simple, if, as is usu- 
ally the case, it lies just under the skin ; it has been found more 
deeply seated, as in the gluteal artery, but it is more frequent on the 
head ; here we may feel, and occasionally see, the tortuous pulsating 
artery, so that the disease is readily recognized ; it is not frequent. 

We have still to mention that the arterial wall may become dis- 
eased by a suppuration or ulceration extending from the neighboring 
parts, first to the adventitia, then to the other coats ; this is the case 
more rarely in acute abscesses than in chronic ulcerations. As an 
example of this we see that, in the development of cavities in the 
lungs, it not unfrequentiy happens that the ulceration attacks the walls 
of the smaller arteries, and the adventitia is partly destroyed and 
softened. The result of this is, that the artery dilates at this point. 



ATHEROMA OF THE ARTERIES. 583 

and a small aneurism is formed, whose rupture causes severe haem- 
orrhage. Other ulcerations also may (though this rarely happens) find 
their way to an artery and destroy its walls, so as to induce bursting 
of the artery, and fatal haemorrhage if the artery be a large one. I 
have seen several such cases : an old man had an abscess deep in the 
neck which opened into the pharynx; this was diagnosed from the 
gradual formation of a painful swelling in the neck and the free ex- 
pectoration of badly-smelling pus ; the patient had only been in the 
hospital a few hours when he threw up a large amount of blood, was 
quickly asphyxiated, and died ; autopsy showed that, as a result of cir- 
cumscribed suppuration of the superior thyroid artery, it had thrown 
out a quantity of blood which had passed directly into the larynx and 
caused suffocation. In another case in a young man who had caries 
of the right temporal bone, there were repeated haemorrhages from the 
right ear ; I diagnosed an abscess on the under side of the temporal 
bone with suppuration of the internal carotid artery. The bleeding 
could not be checked by tampons to the ear ; I ligated the right com- 
mon carotid. The bleeding ceased for ten days, then began again ; af- 
ter repeated tamponading and digital compression of the left carotid 
without permanent result, I also ligated the left common carotid ; but 
in two days the patient died of profuse haemorrhage from the right ear, 
nose, and mouth ; the abscess, which was filled with blood, and could 
now be regarded as an aneurysma spurium, had also opened into the 
pharynx. The post mortem fully confirmed the diagnosis. 

We now come to chronic diseases of the arteries and their results, 
to true aneurisms. In advanced age it is very common for the arteries 
to become exceedingly thick and hard and occasionally even looped, 
especially those of the diameter of the radial or smaller. If we ex- 
amine these arteries more accurately, we find the tunica intima 
thickened, of cartilaginous firmness, it is more rigid than usual, and 
gapes ; in places it is even as hard as chalk, or even quite calcified or 
ossified. The chalky parts are not diffusely spread through the walls 
of the artery, but form circles corresponding to the transverse muscles 
of the tunica media; it is the muscles of the vessels that ossify. 
In such persons, on the inner surface of the aorta and its first large 
branches, we find whitish-yellow spots, striae or plates of chalky firm- 
ness, or rough as if gnawed, with their edges hollowed out. If we 
cut into these spots, we find the whole intima of cartilaginous hardness, 
whitish yellow, and completely calcareous or hard as bone, or else 
friable, granular, or pulpy. Where this disease has attained a high 
grade, the arteries become bulged out. This is atheroma of the ar- 
tery as it appears in the cadaver. We often find the recent and old 
stage near together or in different arteries. If we examine these spots 



584 VARICES AND ANEURISMS. 

more carefully with the microscope, especially in fine cross sections 
through spots of different appearance, we find that the first changes 
occur in the outer layers of the intima, on the boiders of the media; 
here a moderate grouping of cells begins. The young cells may lead 
to connective tissue and new formation and callous thickening of the 
arterial wall ; but they are usually short-lived ; while new ones ap- 
pear in the periphery of the affected spot, the first ones disintegrate 
to a granular detritus, to a pulp formed of fine molecules and fat, 
which remains rather dry, as in caseous degeneration ; the destruction 
thus slowly extends laterally, the nutrition of the media, as well as 
of the inner layers of the intima, suffers ; the muscle-cells of the for- 
mer become granular and fatty, as do the elastic lamellae of the in- 
tima ; the change thus progresses inward till the last lamellae and the 
epithelial membrane are perforated, and the cavity filled with ath- 
eromatous pulp opens into the calibre of the artery. The atherom- 
atous process, beginning as a hollow ulcer, has led to an open ulcer 
with undermined edges ; you see the mechanism is the same that you 
have already seen in the skin and lymphatic glands ; there is a chronic 
inflammation ending in caseous degeneration, or, as the pulp is called 
in this position, in atheroma. This is the essential part of the pro- 
cess, as far as concerns the development of aneurism ; but there are 
some variations, from the different structures of the arteries. The 
less, developed the muscularis and intima, the less atheromatous pulp 
will be formed, as this results chiefly from breaking down of the 
intima. To commence with the small arteries, whose diseases we 
may study in the microscopic cerebral arteries : here we find the col- 
lections of cells mostly in the adventitia, which is but little and only 
secondarily affected in large arteries. Almost the whole adventitia 
changes to cells, the few muscular cells atrophy, the fine hyaline 
membrane, which acts as intima, is very elastic ; thus the softening of 
the adventitia, caused by the cell-infiltration, soon induces dilatation 
and finally bursting of the artery, as the walls are no longer suffi- 
ciently firm to resist the pressure of the blood. Occasionally also 
there is a plastic production of adventitia ; club-shaped vegetations 
form, which consist partly of newly-formed fibrous, partly mucous 
connective tissue. We cannot here discuss this further, especially as 
it does not affect surgery. A fatty degeneration and calcification of 
the muscular coat also occur along with the plastic infiltration of the 
adventitia in the smaller cerebral arteries, but are not frequent. Let 
us pass to arteries the size of the basilar, radial, etc. Here the plas- 
tic process in the adventitia occasionally still combines with those in 
the other coats, although pulpy disintegration and calcification of the 
latter do occur. Sometimes there are thickening and looping of these 



ATHEROMA OF THE ARTERIES. 585 

arteries, sometimes disintegration and softening, with consequent dila- 
tation or aneurism ; for, when the media and adventitia become soft- 
ened to atheroma pulp at some point, the adventitia is no longer 
strong enough to resist the pressure of the blood, and it bulges. If 
we now turn to the large arteries, aorta, carotid, subclavian, iliac, and 
femoral, in which, you know, the muscular coat is reduced to a mini- 
mum, or is even occasionally wanting, while the intima is oomposed of 
a large number of elastic lamella?, and lies almost immediately on the 
adventitia, which has more or less elastic filaments — here there is 
least plastic process in the adventitia ; the pathological change, the 
disturbance of nutrition, evinces itself chiefly in rapid breaking down 
or calcification of the pathological new formation, which occurs partly 
on the borders of the intima, partly in that coat. As already men- 
tioned, cases do occur where extensive circumscribed connective-tissue 
new formations occur in the intima in the form of cartilaginous callosi- 
ties ; but this is rarer than the change to atheroma-pulp. In the last 
mentioned arteries true atheroma pulp forms most frequently, hence 
aneurisms are most frequent in them. If you examine this atheroma- 
purp microscopically, besides the above-mentioned molecular and fat 
granules, you find fat-crystals, especially of cholesterine, and crumbs of 
carbonate of lime, also hasmatoidin-crystals, which come from blood- 
clots depositing on the roughnesses in the arteries, but the hasmatoidin 
develops from their coloring matter. 

You have now a general view and description of atheroma in ar- 
teries of various calibre, and can now understand how, by softening 
the walls of the vessels, it may lead to partial dilatation of the artery, 
or aneurism. The form of this dilatation may vary somewhat, accord- 
ing as the whole periphery of the artery is regularly diseased or not, 
and as softening or calcification predominates. 

The dilatation of the artery may for some distance be perfectly 
regular ; this is called aneurysma cylindriforme ; if the aneurism be 
more spindle-shaped, it is termed aneurysma fusi for me. If the soft- 
ening be limited to one side of the arterial wall, we have a sac-like 
dilatation, aneurysma saccatum, which may communicate with the 
calibre of the artery by a larger or smaller opening. A further variety 
in the formation of the aneurism may arise from all the coats regu- 
larly participating in the formation of the aneurism, or from the 
intima and media being entirely softened and destroyed, so that only 
the gradually-thickening adventitia and infiltrated surrounding parts 
form the sac. Finally, under the last conditions the blood may press 
in between the media and adventitia, separate the two coats, as if the 
layers of the artery had been dissected up anatomically ; this is called 
aneurysma dissecans. These divisions may be carried still further, 



586 VARICES AND ANEURISMS. 

but practically they have very little value. I shall only mention in 
addition that, on subcutaneous bursting of an aneurism composed of 
all the arterial coats, it assumes more the anatomical peculiarities of 
an aneurysma traumaticum or spurium. A short time since I saw an 
apparently healthy man, about fifty years old, who, when turning in 
bed, had an enormous tumor develop in the thigh, which soon proved 
to be a diffuse traumatic aneurism ; I had no doubt that the femoral 
artery was diseased, and had suddenly burst at some point in the 
middle of the thigh. After compression had long been used in vain, 
the femoral artery was ligated ; it proved to be covered with yellow 
spots ; the ligature healed well and became detached in four weeks, 
still the aneurism became larger and painful ; the sixth week after 
the ligation gangrene of the foot began ; I then made a high amputa- 
tion of the thigh ; the patient recovered. There was an immense aneu- 
rysma spurium, and an opening an inch long in the atheromatous fem- 
oral artery, which was not aneurismatic. 

The further fate of the aneurism, and its effect on neighboring 
tissues or the extremity affected, are very important. As regards the 
anatomical changes in and about an aneurism, one is its increase in 
size, which not only displaces the neighboring tissues, but, by its 
pressure and pulsation, causes them to atrophy ; this refers not only 
to the soft parts but to the bones, which are gradually broken through 
by the aneurism ; the last effect is especially apt to be induced by 
aneurisms of the aorta and anonyma, which may induce atrophy of 
the vertebrae, sternum, or ribs. A further accompaniment is inflam- 
mation in the immediate vicinity, which, however, rarely leads to sup- 
puration, often becomes chronic, and very seldom induces gangrene 
of the anurism. Lastly, there is often coagulation of blood in the 
aneurism ; hard layers of fibrine may form on the inner surface of the 
sac, and at last entirely fill it, and so cause a spontaneous oblitera- 
tion, one variety of cure of the aneurism. The worst accident is 
when the aneurism increases in size, and finally bursts; this may 
take place outwardly, but more frequently, especially in the large 
arteries of the trunk, it is inward, perhaps into the oesophagus, tra- 
chea, thoracic or abdominal cavity; sudden death from haemorrhage 
is the natural result. 

It is not our present object to show wnat may be the results of 
aneurism of arteries of internal organs ; I shall merely mention that 
particles may be detached from the clots which form in the aneurismal 
dilatations, or on the roughnesses of the atheromatous arteries, and 
may pass as emboli into the peripheral arteries. These emboli occa- 
sionally cause gangrene ; but this is not so frequent as is believed, 
for usually the coagulae in aneurisms are firmlv attached. 



ANEURISMS OF THE EXTREMITIES. 587 

We shall now investigate more carefully aneurisms of the extrem, 
ities. At first, they cause slight muscular fatigue and weakness, more 
rarely pain in the affected limb ; if there be inflammation about the 
sac, of course there are pain, redness of the skin, oedema, and disturb- 
ance of function, which may go so far as to render the limb entirely 
useless if the aneurism continue to grow, and there be continued 
chronic or subacute inflammation around it. The formation of exten- 
sive coagulae in the aneurism of a large artery may be followed by 
gangrene of the whole limb below it. 

When speaking of gangrene, it was mentioned that it might 
result from atheroma of the artery, as so-called gangrena spon- 
tanea ; but there the case was somewhat different : the small arteries 
were diseased ; these lose their power, from destruction of their strong 
muscular coat, and can no longer urge on the blood, as they cannot 
contract. But here there is obliteration of an arterial trunk by coag- 
ulae from an aneurism. I will relate to you a case observed in the 
Zurich surgical clinic. A man twenty-two years old, emaciated and 
miserable, was brought into the hospital ; his right leg, nearly as high 
-as the knee, was bluish black, the epidermis peeled off in shreds ; gan- 
grene was unmistakable. Examination of the arteries showed a spin- 
dle-shaped, pulsating aneurism of the left [right ?] femoral artery, close 
below Poupart's ligament ; there was a second one, three inches below, 
on the same artery ; this felt hard ; there was a third one in the bend of 
the knee, just as hard, but, from the swelling of the surrounding parts, 
the form could not be exactly made out ; between the second and 
third aneurisms the artery continued to pulsate the first day the pa- 
tient was in the hospital ; the line of demarcation was not formed, it 
appeared likely to extend higher ; gradually the pulsation ceased as 
high as Poupart's ligament ; the patient died about a fortnight after 
his admission to the hospital. The autopsy showed the aneurisms 
that had been recognized during life, and also extensive atheroma of 
almost all the arteries. Taking this with what I told you, when speak- 
ing of the ligation of large arteries, about the development of collateral 
circulation, you will think there is a contradiction. Why does not 
gangrene occur when you close an artery by a ligature, as well as 
when it is blocked by a clot ? The answer to this is, that a free 
collateral circulation sufficient for the nourishment of the peripheral 
parts only takes place when the arteries are healthy and capable of 
distention. But, when a coagulum passes from an aneurism into the 
artery, the neighboring arteries are usually diseased and not disten- 
sible, being calcified, or already partly obstructed ; moreover, the 
closure of the artery is not, as in ligation, limited to a small space, but 
is very extensive, perhaps even, as in the case above mentioned, in- 



588 VARICES AND ANEURISMS. 

volving the whole artery ; then there is no possibility of a collateral 
circulation, either by the direct route or by neighboring branches. 
The arteries must be very generally diseased, and the coagulation 
very extensive, to cause gangrene, so that it is not very frequent in 
aneurism ; that would also be very unfortunate for the treatment, 
which, however, as you will hereafter see, chiefly has for its object the 
obliteration of the aneurism, with or without ligation of the artery. 

We now come to the etiology of aneurism. Although atheroma 
is a very frequent disease of old age, and occurs everywhere, aneurism 
is by no means confined to old persons. In Zurich, atheroma of the 
arteries in old persons, and gangrena senilis, are quite frequent, but 
aneurism of the extremities is rare. The occurrence of aneurism is 
curiously spread over Europe : in Germany, aneurism of the extrem- 
ities is rare ; it is somewhat more frequent in France and Italy, and 
most frequent in England. It is difficult to explain this, only it is 
certain that diseases of the arteries, in common with rheumatism and 
gout, are more frequent in England than in any other country of Eu- 
rope. [During the past five years (1865-1870), of 11,344 cases of 
disease and injury, in the New- York Hospital, there were 33 cases of 
aneurism, or about one case to everj^ 344 patients. Of these there 
were : of the thoracic aorta, 6 ; abdominal aorta, 10 ; innominate artery, 
1 ; subclavian, 2; iliac, 1; femoral, 4; popliteal, 8; not named, 1.] As 
regards age (of course we are not speaking of traumatic aneurisms), 
the disease is rare before the thirtieth year, more frequent between 
thirty and forty years, and most frequent after the fortieth year ; men 
are more disposed to aneurisms than women. Special causes are little 
known ; popliteal aneurism is most frequent among those in the ex- 
tremities ; the explanation of this has been sought in the superficial 
position of the popliteal artery, in the tension to which it is subjected 
on sudden movements, contusions, etc. ; thus this form is said to occur 
especially often in England in footmen who stand behind the carriages ; 
but I must acknowledge that to me this seems as improbable as the 
explanation given for chamber-maid's knee. I am inclined to believe 
that the tendency to diseases of the artery, as to gout, is due to heredi- 
tary influence ; hard work and free use of liquor are also given as causes ; 
in England especially, the latter is said to induce relaxation of the 
walls of the artery, even without atheroma. 

The diagnosis of an aneurism of the extremities is not difficult, 
if the examination be careful and the aneurism not too small. There 
is an elastic, more or less hard, circumscribed (except in false or rup- 
tured aneurism, which are diffuse) tumor connected with the artery ; 
the tumor pulsates perceptibly to the sight and touch ; on applying 
the stethoscope, you may hear a pulsating murmur, caused by the fric- 



DIAGNOSIS OF AXEURISM. 589 

tion of the blood on the coagulum, or in the opening of the sac, or by 
the ricochetting of the blood in the sac. The tumor ceases to pulsate 
if you compress the artery above it. These symptoms are so striking 
that it might be thought the diagnosis could not be mistaken ; still, 
errors have been made even by experienced surgeons, at times when 
they did not think of the possibility of aneurism, and were hasty. 
For, when the surrounding parts are much inflamed, the aneurism may 
be greatly masked by the swelling ; it may be taken for a simple in- 
flammatory swelling or abscess ; it may even have originated from an 
abscess, as before stated. The latter mistake is the most frequent ; it 
is punctured, and — what a disagreeable surprise — instead of pus, we 
have a stream of arterial blood. There is nothing at hand to arrest 
the haemorrhage ; the situation is shocking, even if the cool surgeon 
have presence of mind enough to make instantaneous compression 
till he decides what next to do. But I will not picture affairs too 
dismally; and I repeat that, on careful examination, such an error 
would scarcely be possible. If the aneurism be distended with clots, 
the pulsation of the tumor may cease, or be very indistinct, as may 
also the murmur ; even here, however, further accurate observation 
will lead to a correct judgment. On the other hand, a tumor of a dif- 
ferent sort may be mistaken for an aneurism. In the bones particu- 
larly, there is a sort of soft tumor (central osteosarcoma) which is 
very rich in arteries, and consequently pulsates distinctly. Numerous 
small aneurisms may form on these arteries, from the softening of the 
substance of the tumor and of the walls of the arteries ; the sum of 
the murmurs in these small aneurisms may resemble a typical aneu- 
rismal murmur ; in these cases also, only the most accurate examina- 
tion and observation can show us the true state of the case. These 
pulsating bone-tumors are often regarded as true aneurism in bone. 
I do not believe there is any spontaneous aneurism in bone, but con- 
sider all these so-called bone-aneurisms as soft sarcoma in the bone 
very rich in arteries. Lastly, we may be tempted to regard a tumor, 
lying very near an artery and moved with the arterial pulse, as an in- 
dependently-pulsating tumor, or an aneurism ; the absence of the 
aneurismal murmur, the consistence of the tumor, the possibility of 
isolating it from the artery, and the further observation of the course, 
will guard you from error. The 2^'ognosis of aneurism varies greatly 
with its locality, so that nothing general can be said of it. 

We now turn to the treatment, remarking, first, that in rare cases 
aneurism may recover spontaneously, by complete closure of the sac 
and a part of the artery by coagula ; the tumor then ceases growing, 
and may gradually subside. As before mentioned, also, inflammation 
around the tumor may lead to local gangrene ; if the artery has pre- 



590 VARICES AND ANEURISMS. 

viously been occluded, the whole aneurism may become gangrenous, 
and be thrown off without haemorrhage. These natural cures are 
very rare, but indicate the mode of treatment. I shall not here speak 
of the medical treatment of aneurism, except to mention one method, 
Valsalva's. The aim of this is, to reduce the volume of blood in the 
body to a minimum, so as to weaken the heart's action, and favor the 
formation of coagula. Repeated venesections, purgatives, absolute 
quiet, low diet, digitalis internally, and ice locally over the tumor, are 
the remedies with which the patient is treated under this method ; the 
results are doubtful : the patients are very much debilitated, and the 
symptoms may then be less; but, as the patients regain their strength, 
the former condition generally returns. We may employ the above 
remedies to a moderate extent in alleviating severe symptoms in in- 
ternal aneurisms, but they will not induce an actual cure ; unfortu- 
nately, internal aneurisms must almost always be regarded as incura- 
ble. Let us pass to the surgical treatment of external aneurisms. 
This may be conducted in two ways ; it may aim at the destruction of 
the aneurism, or its complete removal. In most cases the destruction 
of the tumor will be enough. The remedies for this purpose vary. 

1. Compression. This may be applied in various ways : «, on the 
aneurism ; b, on the affected artery, above the tumor. The latter is 
by far the most effective method, because even a moderate pressure 
on the aneurism is often painful, and may cause inflammation in its 
vicinity. The mode of employing compression also varies ; it may be 
continued, and complete or incomplete ; it may be temporary, but com- 
plete, i. e., such as to arrest the pulsation. The methods of compres- 
sion are about as follows : a, compression with the fingers, particularly 
recommended by Vanzetti, and used by other surgeons with advantage ; 
it is made by the surgeon, nurses, or by the patient himself, at inter- 
vals, so as to arrest pulsation completely for a few hours ; if the patient 
can bear it, this is continued for days, weeks, or even months, till the 
aneurism no longer pulsates, and has become quite hard ; b, compres- 
sion of the aneurism by forced flexion of the extremity ; this procedure, 
first used by Malgaigne, is particularly suited for popliteal aneurism ; 
the limb is fastened in the position of extreme flexion by a bandage, 
and retained thus till the pulsation in the aneurism has ceased ; 
c, compression with special apparatus, pads, compresses, etc., which 
must be so made that the pressure may be as much as possible 
on the artery, and that oedema may not be induced by simultaneous 
pressure on the vein ; the pressure need not be hard enough to arrest 
pulsation entirely, but merely to diminish the supply of blood. Views 
regarding the efficacy of compression in the treatment of aneurism 
vary. Irish surgeons laud it highly; French and Italian surgeons 



TREATMENT OF ANEURISMS. 591 

incline to it more than formerly ; especially since the investigation? 
of Broca, intermittent digital compression has shown some brilliant 
results. I think that, in most cases of aneurism, compression should 
be first resorted to ; but observation shows that it is not alike suited 
for all cases, and is not of radical benefit in all. [Mr. Coote reports a 
case where aneurism of the innominate artery was cured by the appli- 
cation of a bladder of ice.] 

2. Ligation of the artery. This may be done in various ways : 
a, close above the aneurism (after Anel) ; b, far above the aneurism, 
at a point of election (J~. Hunter) ; c, close below the aneurism, i. e., 
at its peripheral end (after War drop and Brasdor). Of all these 
methods, ligation close above the aneurism is proportionately the 
most certain ; ligation close below it the least certain. Ligation at 
a distance from the aneurism will cure the disease for a short time, 
occasionally even permanently, i. e., the pulsation in the aneurism 
will cease, but, when the collateral circulation develops fully, the 
pulsation may begin again. I have myself seen such a case ; from a 
puncture with a penknife, a boy twelve years old had an aneurism 
the size of a large walnut in the femoral artery, about the middle of 
the thigh ; the femoral was ligated close below Poupart's ligament ; 
in ten days the ligature cut through, and there was great haemor- 
rhage, which, however, was instantly checked ; then, after dividing 
Poupart's ligament, a second ligature was applied half an inch higher ; 
this ligature held well ; the wound healed ; when the patient left the 
hospital there was again pulsation in the aneurism, which had previously 
become perfectly hard, and had ceased pulsating. But, in spite of such 
relapses, ligation remote from the aneurism will retain its importance, 
and continue the chief method, for, in the vicinity of the aneurism, 
the artery is occasionally so diseased that it is not advisable to ligate 
there ; for the rigid and ossified artery might be so quickly cut 
through by the ligature that the thrombus would not be firm enough 
when the ligature falls. 

3. Remedies which are supposed to directly induce coagulation of 
the blood in aneurisms. Of these, injection of liquor ferri sesqui- 
chlorati, after Pravaz and JPetrequin, is relatively most frequently 
used ; it must be done very carefully : it should be made with a small 
syringe, whose piston is moved by a screw, with every turn of which 
a drop escapes ; a few drops of the liquor ferri should thus be very 
carefully forced into the tumor. Simple coagulation and shrinking 
of the aneurism may, and it is said do, follow this ; but experience 
has shown that it is more frequently followed by inflammation, sup- 
puration, and gangrene. I think that the action of the injected liquor 



592 VARICES AND ANEURISMS. 

ferri is misunderstood ; for it is not probable that a clot made by this 
substance becomes organized ; it most likely merely irritates the wall 
of the vessel, causing it to inflame, and thereby lose the power of 
keeping the blood fluid (Uriicke), thus secondarily inducing coagula- 
tion of that fluid and atrophy of the walls of the artery. Vb?i Lan- 
genbeck injected a solution of ergotin into the immediate vicinity of 
an aneurism and cured it. I explain the action here also as being an 
inflammation of the wall of the vessel, with the results above men- 
tioned. Electropuncture, nearly abandoned for a time, has been again 
resorted to by Giniselli, and with very good results, even in aortic 
aneurism ; a needle is to be passed into the aneurism and connected 
to the negative pole of a galvanic battery, while the positive pole is 
to be applied to any part of the body. [In an interesting case re- 
ported by Dr. H. JP. Lincoln, in the Medical Record, the current 
.was passed directly through needles introduced into the tumor.] 
Formerly it was thought that the galvanic current had the power ol 
coagulating the blood directly. [This would seem to have occurred in 
Lincohi's case, as clotted blood escaped from the needle-punctures.] 
Physiologists do not consider this the mode of action, but think that 
the thermic effect of the current causes a small eschar around the 
needle in the aneurism, and that the clot forms around this. If we 
pass several fine needles into an aneurism and leave them twenty-four 
to forty-eight hours, they also will cause inflammation and formation 
of a clot. [At a meeting of the New York Pathological Society, Dr. 
G-urdon Buck presented a specimen where needles had been used, 
and spoke of one where silk sutures had been employed ; he gave it as 
his opinion that, in view of the liability to inflammation, such proced- 
ures were inadmissible in arteries near the heart.] 

4. We now come to the mode of operative treatment of an aneu- 
rism which aims at its complete destruction; if this succeed, it is, 
of course, more certainly a radical cure than the modes above de- 
scribed, but it is a much more serious operation. It may be done, 
according to Antyllus, as follows : The artery is to be compressed 
above the aneurism, then the whole sac is slit up and the coagulum 
turned out ; through the sac probes are passed into the upper and 
lower ends of the artery, which is then ligated, the probes of course 
being removed — they are only intended to facilitate finding the artery ; 
this operation, which I have seen performed several times for aneu- 
risms resulting from venesection, is not always as simple as it appears, 
for it is not at all times easy to find the openings of the artery in the 
sac filled with coagulum, and often other arteries besides the main one 
bleed, as a collateral circulation occasionally opens into the aneurism. 



TREATMENT OF CIRSOID AXEURISM. 593 

After the operation there is suppuration of the whole aneurismal 
sac ; in three cases of traumatic aneurism of the brachial, and one of the 
radial artery, I saw healing occur without any accident. If the aneu- 
rism be small and distinctly bounded, we might first ligate above and 
below, then extirpate the aneurism as we would a tumor. Of late, 
Syme has employed the method of Antyllus successfully in large 
arteries also. 

I should like to give you some definite advice about the choice of 
method among these different plans of operating, but this is scarcely 
possible, as one plan or another will best suit different cases. In gen- 
eral terms, I can merely repeat that of late so many favorable results 
from compression have again been published from different sources, 
that it should not be too quickly abandoned. If, however, as usually 
happens in aneurisms from venesection, there be great diffuse swell- 
ing of the entire arm, the method of Antyllus appears to me prefer- 
able to all others ; with good assistants it is very practicable, and is 
not so dangerous as is claimed by many persons. When we do not 
wish to make Antyllus' s operation, we may try AneVs or Hunter's. I 
have least to say for the injection of liquor ferri in ordinary cases of 
spontaneous and traumatic aneurism. In varicose aneurism and 
aneurismal varix, ligating the artery above and below the opening 
will be the most certain method. 

We must still add a few remarks about the treatment of cirsoid 
aneurism. The above methods of operation are only partially appli 
cable to it. Direct compression of the entire tumor may be made by 
means of bandages and compresses prepared for the special cases ; we 
mean particularly the aneurisms of this variety coming on the head 
which are the most frequent, but compression has rarely proved 
successful. The injection of liquor ferri may here prove useful, 
for suppuration or gangrene of the entire convolution of arteries 
is not so much to be feared as in aneurisms of the large arteries of 
the extremities. The destruction might be accomplished by ligating 
all the afferent arteries, but this is very tedious and uncertain ; the 
result would be just as doubtful, and it might be dangerous to ligate 
one or both external carotids in a cirsoid aneurism of the scalp. An- 
other method, having the same object, is to insert insect-needles 
through the skin at different points around the tumor, and apply a 
thread, as in the twisted suture ; the result will be suppuration and 
obliteration, perhaps partial gangrene of the skin. Total extirpation 
may occasionally be resorted to ; it is done as follows : Around the 
tumor we make numerous percutaneous mediate ligations close to- 
gether ; then we may cut out the main body of the tumor, with the 
38 



594 VARICES AND ANEURISMS. 

dilated arteries, without haemorrhage ; this is the most certain and 
radical operation, but cannot well be resorted to when the tumors are 
very extensive ; then we might try mediate ligation for different parts, 
and attain our end by partial extirpations. After his very thorough 
investigations about the treatment of these aneurisms, Seine also 
speaks very decidedly in favor of their extirpation. 



CHAPTER XX. 
TUMOBS. 



LECTURE XLIV. 

Definition of the Term Tumor. — General Anatomical Eemarks; Polymorphism of 
Tissues. — Points of Origin of Tumors. — Limitation of the Development of Cells to 
Certain Types of Tissue. — Eelation to the Generative Layers. — Mode of Growth. — 
Anatomical Metamorphosis of Tumors ; their External Appearances. 

Gentlemen : To-day we enter on the difficult chapter that treats 
of tumors. The swellings of which we have hitherto spoken depended 
only on a few causes ; they were due to abnormal collections of blood 
in and outside of the vessels, to infiltration of the tissue with serum, 
to its permeation with young cells (plastic infiltration), either sepa- 
rately or in combination. In contradistinction to these swellings, we 
now in the clinical sense of the term call new formations swellings 
or tumors when we suppose they are due to other causes than those 
of the inflammatory new formations, and have a growth which as a 
rule has no typical termination, but, as it were, goes on ad infinitum ; 
besides, most of these growths are composed of tissue which is' more 
highly organized than inflammatory neoplasia. Let us investigate 
this more accurately. At present you are only acquainted with that 
variety of new formation caused by inflammation ; this is very uni- 
form, not only in its mode of origin, but in its further development ; 
its development might be interfered with by disintegration, drying up, 
breaking down into pus, etc. ; it might proliferate excessively, but it 
was always in such a way as not to change its character ; but, finally, 
if there existed no specially unfavorable local or general cause, and 
no vital organ was disturbed by the new formation, it subsided — it 
again became connective tissue ; the inflammation terminated in cica- 
trization. Then, if the inflammation was superficial, there was de- 
velopment of epithelial or epidermis cells, the bony cicatrix ossified, 



596 TUMORS. 

new nerve-filaments formed in the nerve-cicatrix ; in all these changes 
the development of new blood-vessels played an important part ; still, 
as above said, the typical termination of the inflammation, whether it 
was acute or chronic, superficial or deep, was in the cicatrix. 

Although connective tissue, nerve, and bone tumors, may ex- 
ceptionally form from connective tissue, nerve, and bone cicatrices, 
still these constitute a very small part of the various tissue-formations 
found in tumors; forms the most varied and complicated, such as 
newly-formed glands, teeth, hair, etc., are occasionally to be found in 
the tumors ; indeed, tissues are there seen which, as then arranged, 
never under other circumstances occur in the body or even during 
fcetal life. To enable you to form a correct idea of the anatomical 
characteristics of tumors, I will recall to your memory a few general 
laws from general pathology about the formation of new growths ; in 
the large works on this subject by Virchow and O. Weber you may 
find very excellent and exhaustive representations of these conditions. 

When a part of the body is abnormally enlarged, we make a dis- 
tinction as to whether the enlargement is caused by an abnormal in- 
crease of volume of the different elements {simple hypertrophy) or by 
a formation of new elements, which are deposited between the old 
ones. This new formation may be analogous to the matrix, or mother- 
tissue (homoeoplastic), or not (heteroplastic). The homceoplastic new 
formation proceeds either from simple division of the existing ele- 
ments (thus a cartilage-cell by segmentation forms two, then four 
cartilage-cells) ; then it is called hyperplastic (numerical hypertrophy) ; 
or at first apparently indifferent, small, round cells form from the ex- 
isting cellular elements, and from these a tissue analogous to the mat- 
rix is developed — homceoplastic new formation in the strict sense. 
Heteroplastic new formations always begin with the development of 
primary cell-tissue, so-called indifferent formative cells (granulation 
stage of tumors, Virchoio), and from these develops the tissue heterolo- 
gous to the matrix (as cartilage in the testicle, epidermis in the 
brain, etc.). 

This nomenclature, proposed by Virchow, seemed perfectly suit- 
able and natural in a purely anatomical point of view ; and I can still 
accept it if the term of heteroplasia be limited, as will be hereafter 
stated, and if we dismiss the idea that homceoplastic is synonymous 
with benignant and heteroplastic with malignant. We must here add 
that there is every probability that wandering cells escaping from the 
vessels very materially aid in the formation of tumors, at least to the 
formation of tumors of the connective-tissue series. But, apart from 
this, we should err if we supposed that in the above nomenclature all 
cases of new formation, even considered in a purely anatomical point 



GENERAL REMARKS ABOUT TUMORS. 597 

of view, could be easily labelled, ready to be placed away in a 
museum. The simple numerical hypertrophies and hyperplasias, al- 
though in some cases difficult to distinguish, are at least theoretically 
separable ; the same way with those new formations which do not 
consist of similar, well-formed tissue-elements ; a connective-tissue 
tumor occurring in connective tissue would always be termed homceo- 
plastic ; found in bone, brain, or the liver, it would be termed hetero- 
plastic, etc. Well-developed alveolar cancerous tissue also usually 
presents no difficulty of classification, for it does not normally occur 
in any part of the body, it is everywhere heterologous. But what 
shall we say of the neoplasias which have no fully-developed normal 
or entirely abnormal form of tissue, but consist of elements that can- 
not be found elsewhere ; what becomes of them ? or, can any thing 
develop from them (indifferent formative cells, primary-cell tissue, 
granulation-tumors) ? and where shall we place those neoplasias which 
are not completed tissue, but are evidently normal tissue in the stage 
of development ? According to the above definition of heterology and 
homology, inflammatory new formation is at first heterologous every- 
where ; but the connective-tissue cicatrix developing from it subse- 
quently becomes a homologous neoplasia in connective tissue ; in mus- 
cle it almost always remains heterologous, the same way in the brain 
and in the bones, if it does not ossify. You see that here parts, 
which from their nature and mode of origin naturally belong together, 
are sundered by the anatomical nomenclature. But let us leave iD- 
flammatory neoplasias out of the question. Every tumor resulting 
from indifferent formative cells must exhibit a series of stages of de- 
velopment, if the cells are transformed to one or several sorts of tis- 
sue. Wherever they are grouped together, indifferent formative cells 
are heterologous ; if a neoplasia show only such elements, we will let 
it pass for heterologous ; but if it appear that a number of these cells 
have been transformed into spindle-cells, the question arises, Where 
does this neoplasia belong? Spindle-cells collected in groups are 
heteroplastic in all parts of the body ; but these cells occur in foetal 
connective tissue, foetal muscles, and foetal nerves ; what would finally 
become of the spindle-cells of this tumor ? if found in muscles, should 
not this tumor still be called homologous ? On this point we can only 
decide arbitrarily ; you may look at it from different points of view. 
Now, what shall we do with tumors that contain the most different 
complete and incomplete tissues ? I will stop here, to avoid makiDg 
you skeptical ; it is nryduty to help you learn, not to throw obstacles 
in your way. 

As the enlargement of the individual elements (simple hyper- 
trophy) cannot be observed, and the increase of the elements from 



598 TUMORS. 

themselves (hyperplasia) is an act often observed and constantly go- 
ing on in physiological growth, it only remains to treat of the point 
of origin of the indifferent formative cells, and their further course. 
Here we find ourselves in the same position as in inflammation, only 
in regard to the development of tumors we unfortunately cannot make 
any experimental investigations. Formerly the proliferation of con- 
nective-tissue cells was not doubted, and these were assumed as the 
source for the development of most tumors. But most, possibly all, 
of these indifferent cells are wandering white blood-cells. There is 
little doubt that on this point there was formerly much error, conclu- 
sions having been too quickly drawn from the arrangement in groups, 
and the metamorphoses of the formative cells ; nor can I claim to have 
escaped these errors. For instance, when in sarcoma we found small 
indifferent cells, w T ith one, two, and then more nuclei near together 
(when between the filaments of the connective tissue, w T here the con- 
nective-tissue cells lie, we saw a small, then, near by, a large group of 
indifferent cells), the conclusion that the new groups of cells were deriv- 
atives from the connective-tissue cells seemed quite unprejudiced ; also, 
that from these indifferent cells, larger multinucleated ones were con- 
stantly developed till the so-called giant-cells were arrived at. Know- 
ing now that an infiltration of the tissue with small cells may depend 
on escape of white blood-cells from the vessels into the tissue ; as be- 
fore remarked, we also become doubtful about the origin of the indif- 
ferent formative cells in the tumors. Of late, especially in glandular 
and epithelial cancer, I usually seek in vain for proliferating connec- 
tive-tissue cells, although the whole connective-tissue layer of these 
tumors is generally infiltrated with young cells. The deep ob- 
scurity which had surrounded the origin of young epithelial cells 
has only lately been cleared away. From the latest investiga- 
tions we know that these cells increase by a sort of segmenta- 
tion. I must here remind you of what was said about the regen- 
eration of tissue in inflammation (Lecture XXII.). From AmohVs 
observations we may suppose that, in the development of tumors ? 
protoplasm which has been fully changed to tissue may possibly pass 
into a granular condition, a nucleus may form in it, and it may then 
proliferate, and segmentation occur as it does in cells \ in which 
case new tissue is first formed when the granular protoplasm has 
changed into cells; so that Schwann^ law that "all tissues are 
formed from cells " is not broken, although there is a modification of 
the law that " every cell comes from a cell." 

We have frequently spoken of indifferent formative \ cells , without 
having sufficiently defined this term. By these we mean the small, 
round cells which everywhere first appear after irritating the tissue, 



GENERAL REMARKS ABOUT TUMORS. 599 

and with which we became acquainted in inflammatory new forma- 
tions. Until within a few years I believed that these young cells 
were actually as indifferent as the primary segmentation-globules of 
the egg [vitelline spheres of Dalto?i], i. e., that any tissue might 
finally develop from them ; and more especially I thought that not 
only all forms of connective-tissue substances (connective tissue, 
cartilage, bone), vessels, and nerves, but also epithelial tissues, 
glands, etc., could proceed from the derivatives of the connective- 
tissue cells. Against this still prevalent view Thiersch, in an excel- 
lent work on "epithelial cancer," has produced such proofs that I 
must entirely agree with him. As I propose returning to this point 
hereafter, when treating of cysts, glandular tumors, and epithelial 
cancers, I shall here merely point out the general outlines of my 
views. From the account of development you know that the body 
of the young embryo very early shows three different layers, so- 
called germ-layers. As soon as the division of the cellular embryo- 
nal elements into the three germ-layers is accomplished, all observers 
agree that each of these three germ-layers produces only a certain 
series of tissues. From the horny layer are formed the nerve-sys- 
tem, the epidermis, and their derivatives, the cutaneous glands, the 
sexual glands, the labyrinth of the ear, the lens ; from the middle 
germ-layer are formed the connective substance, the muscles (?), the 
vascular system, the lymphatic glands, the spleen, the peripheral 
nerves (?) ; from the inferior or glandular layer are formed the epi- 
thelium of the intestinal canal, that of the lungs (?), all the secret- 
ing elements of the liver, pancreas, kidneys, etc. This is one of 
nature's laws, for whose discovery we are greatly indebted to Re- 
mak, Meichert, Kolliker, Heis, Waldeyer, and others, and which 
may probably be carried back into the composition of the ovum. 
In the whole subsequent course of development a derivative of one 
germ-layer never develops a tissue which was originally formed 
from another ; in other words, if the division of the cellular embryo- 
nal plan has advanced to the three germ-layers, there are no more 
wholly indifferent cells, but all newly-formed cells developed from 
previous ones can only develop to tissues lying within the territory 
of the germ-layer whence they originate ; cells originating from 
true genuine epithelium can never produce connective tissue, and 
true epithelium or glands can never come from the derivatives of 
connective-tissue cells. There is no reason for supposing that the 
natural law would be annulled if the cellular elements of the com- 
plete organism were excited to production by any irritation ; the 
young brood can only develop to certain prescribed types of tissue, 
which depend on the embryonal origin of the mother-cells. When 



600 TUMORS. 

we have spoken, or in future speak, of indifferent cells, you must al- 
ways limit the expression by the principles above developed. If we 
now return to the system of new formation developed by Virchow, 
according to our view there is no such thing as a true heteroplasia, 
for the germ-cells formed from the derivatives of one germ-layer can 
only develop differently within certain bounds ; they can never be- 
come one of the types of tissue belonging to another germ-layer. 
From the great movements constantly being made in histogeny, 
any very absolute assertion is in danger of being obliged soon to 
submit to some modification ; still I must repeat that it seems to 
me in the highest degree probable that a large part of the young 
cells escaping so extensively into the tissues during the develop- 
ment of tumors are movable, wandering, connective-tissue cells, that 
is, escaped white blood-cells. Nevertheless, I would not deny to 
the stable elements all participation in the new tissue formation. 
For instance, it has been proved of muscular filaments that their 
cells proliferate after irritation, by division of the nuclei, although 
this may not occur for some time (in rabbits about the end of the 
first week) ; the same is true of the nerves ; the cartilage-cells also 
react on irritation, although not for some time. It is uncertain 
whence the wandering cells come (they are identical with white 
blood-cells and lymph-cells) ; probably their original source is from 
stable elements of the lymphatic glands and spleen ; at all events, 
they must be regarded as elements of the middle germ-laj^er, and 
hence their powers of development must be regarded as limited to 
the tissues of this layer. Our times may look with pride at the pro- 
gress of modern morphology, whose importance is proved by the 
very fact that it is so destructive to previous views and so fruitful 
in the most diverse directions. 

When some investigators on this point assert that the conditions 
of embryonal development just given have no claim to pass as im- 
mutable laws of nature, but only serve as rules for the development 
of the more highly-organized animals, I must leave the embryologists 
to maintain the argument. But I would entirely deny the assertion 
that types of development which are recognized in embryology have 
no analogy in neoplasms which result from various irritations of de- 
veloped tissue ; for all modern histogeny is based on the principle 
that development of pathological neoplasia is only a repetition of 
typical development of normal tissue, which has been generally ac- 
cepted since Johannes Mullens pioneer work on tumors. If we 
lost this principle, we should lose all our hold on this domain and 
fall back into the old chaos of parasites and pseudoplasms. 

Let us now return to tumors. Their life and growth may vary 



GENERAL REMARKS ABOUT TUMORS. 601 

greatly. In the first place, the diseased portion of tissue, the first 
tumor-nodule, may grow in itself, without new points of disease de- 
veloping in its vicinity ; in the midst of the tumor itself, from the 
cells collected at a circumscribed spot, new ones constantly form, 
with a tendency to develop in the same direction, predestined as it 
were for the type of development taken by the new formation. It 
was formerly supposed that the distention of the vessels was a very 
essential indication of inflammatory neoplasia ; numerous researches 
in this direction have shown me that the enlargement and new for- 
mation of vessels in the development of the first tumor-nodules are 
not inferior to those in inflammation. It has not yet been proved 
that there is a softening of the capillary and venous walls, as in 
inflammation. The original focus of disease may also grow by new 
foci constantly forming in its immediate vicinity ; an organ once 
diseased in this way is not only compressed by the tumor, and its 
elements separated, but it becomes more and more diseased, and so 
becomes infiltrated and destroyed by the tumor, and is finally trans- 
formed into it ; for you have already seen that a neoplasia forms in 
normal tissue, the matrix ceases to grow, and is-partly transformed 
into the new tissue, partly is destroyed. So in the first case we have 
an isolated focus of disease which, once existing, draws the material 
for its increase from its own cells; in the second case we have a con- 
tinual extension of the foci of disease. The first variety, the to some 
extent pure central growth, is decidedly less unfavorable to the organ 
diseased than the latter, the peripheral growth, which, when it con- 
tinues ad infinitum, must cause complete destruction of the organ, 
just as when an inflammation or inflammatory new formation continues 
progressive. A combination of these two modes of growth is the most 
unfavorable, but unfortunately is quite frequent. If we study the life 
of the tumor itself further, we find that the neoplastic tissue does not 
by any means remain stable, but is subject to some changes, such as 
are also seen in inflammation. From various causes, acute and chronic 
inflammations may develop in the tumors, i. e., with pain, swelling, 
and enlargement of the vessels ; there is an infiltration of small cells 
into the tissue of the tumor, which may even lead to suppuration; this 
disease of a tumor is the more frequent the less its elements are or- 
ganized to a stable vital tissue, especially the less its vascular system 
is regulated and fully organized. Tumors in which the cell-formation 
is so excessive and progresses so rapidly that the formation of vessels 
only follows up the growth of the tumor slowly are least capable of 
living ; slight disturbances then suffice to impede the whole process of 
development, or, as they do not arrest it entirely, to cause destruction. 
We must examine somewhat more minutely the metamorphosis of the 



602 TUMORS. 

tissue of tumors in inflammations. They may come on in an acute or 
chronic manner; acute inflammations are on the whole rare, still they 
may be induced by injuries, blows, or contusions ; this traumatic in- 
flammation in vascular tumors rich in connective tissue may terminate 
in resolution with or without cicatricial contraction, but frequently 
they are followed by more or less extensive extravasations, gangrene, 
or suppuration. Chronic inflammations in tumors are far more fre- 
quent, both those characterized by production of inflammatory neopla- 
sia, fungous ulcerations with great vascularization, and those marked 
by torpid ulceration. Caseous and fatty degeneration of the tissue and 
its breaking down into mucous fluid are not very unfrequent occur- 
rences. In these processes of softening there are thrombosis and col- 
lateral dilatation of the vessels around the softening point, as in the 
transformation of a focus of inflammation to an abscess or to caseous 
matter. All these changes, by development and disease of the tumor, 
may so complicate its appearance as to render it sometimes difficult 
at once to tell correctly, in any given case, what was the original tissue 
of the tumor. Lastly, it sometimes happens that in the course of time 
tumors change their anatomical state; for instance, a connective-tissue 
tumor which had long continued in that state becomes softer by rapid 
proliferation of cells and greater vascularization; or, on the contrary, a 
soft tumor becomes hard from atrophy of the cells and cicatricial con- 
traction of the connective tissue existing in the tumor. So you see 
what an amount of knowledge and experience is necessary merely to 
judge correctly in each case of these anatomical conditions, w 7 hich 
form the basis of all our knowledge of tumors; indeed, w r e may occa- 
sionally be unable to give to the object we have examined a name 
by which it may be simply labeled in one of the regular groups ; as 
regards the nomenclature of tumors which are composed of various 
tissues, we generally choose the name from the tissue that is present 
in the tumor in the largest amount. 

It has been generally agreed .to append tipa to the name of the 
affected tissue, to characterize a tumor histologically ; as sarcoma, 
carcinoma, etc. There was no word cofia among the Greeks; it came 
from giving certain nouns the termination ow to make them verbs, 
as : odpi;, flesh, oapttoo), to make flesh ; napnivog, cancer, Kapfeivoo, to 
make like cancer. The Greeks used the expression odpKOdfia, fleshjr 
tumor, Kapfcivo/jLa, cancer, ulcer (Hippocrates). Modern nomencla- 
ture has been developed from this, and has been carried out by 
Virchow with especial thoroughness. The old Grecian term for tu- 
mor in general is oynog, bend, bending, bulk, mass, etc. ; hence Vir- 
chow has termed the study of tumors " onkologie." The term <f>v[ia, 
4>vtov, growth, also used by Hippocrates, is now rarely employed. 



NOMENCLATURE OF TUMORS. GO 3 

Celsus occasionally designated tumors in general as " struma," but 
glandular tumors on the neck were more especially meant. The 
English term " strumous " what we call " lymphatic, scrofulous." 
The Germans confine the term " struma " to tumors of the thyroid 
gland. 

I have little to say about the external gross appearances of tumors. 
In most cases the growths are roundish nodules, more or less distin- 
guishable, by sight and feeling, from the surrounding parts. This is not 
always accurate, however ; tubercles also, at least in their smallest state, 
are bounded roundish bodies, which I should no more class among the 
growths than I should papules and pustules of the skin. In the skin 
also a distinctly-formed nodule may appear as a growth, just as an 
abscess may which also at first appears as a nodule. Still, as chronic 
inflammatory new formations on the surface also frequently appear in 
the form of papillary proliferations (tufts), a growth forming on the 
skin or mucous membrane may also assume the papillary form ; even 
the surface of a tumor, or a newly-formed cavity containing fluid or 
pulp, may produce papillary proliferations. So you see that growths 
and inflammatory neoplasia are not accurately distinguishable by their 
purely external anatomical conditions. 

There are a number of terms for different }3eculiarities of tumors, 
which are frequently used even now, although they do not always 
refer to any essential point. Thus, a tumor situated in a cavity, and 
attached by a pedicle, is called a polypus / so, we speak of nasal 
polypi, uterine polypi, etc., but must add the histological peculiarities 
(as fibrous, myxomatous, etc.). Growths that are ulcerated and pro- 
ject like a fungus are called spongy ', or fungous. Formerly, if one 
wished to say that a tumor was very vascular, he used the word " ne- 
matodes," while to-day it is called " telangiectatic," or " cavernous." 
If a tumor was very firm or fibrous (not cartilaginous or bony) it was 
formerly called " scirrhous," which merely means " firm," and was 
applied- to inflammatory new formations just as to cancer. A tumor 
was called medullary when it had the color and consistence of the 
brain, while its structure might be that of sarcoma, carcinoma, or 
lipoma. As tumors of this appearance are recognized as peculiarly 
malignant, the terms "medullary sarcoma," "medullary carcinoma," 
have been applied to malignant tumors in general without regard 
to their structure. Some growths are colored — brown, yellowish, 
brownish black, bluish black; this pigmentation may be due to 
extravasations, or to specific cell-activiy. Melanomata or mela- 
noses are rare, partly or entirely black or brownish-black tumors, 
with the structure of sarcoma or carcinoma, and usually of very bad 
prognosis. Formerly only these and similar terms, and comparisons 



604 TUMORS. 

to this or that tissue, were used ; it is enough for you to know what 
they mean. 

We must again return to the term " tumor." Pure anatomy should 
simply reject this term, for it acknowledges only simple or composite 
tissue-formations (organized neoplasia of MohitansJcy) ; from a series 
of observations it can show how these structures develop, and what 
becomes of them ; we shall not thus arrive at the term " tumor " in 
the sense in which we use it in pathology. Tumor, or growth, in the 
pathology of to-day, has a decidedly etiological and prognostic signi- 
fication ; as stated at the opening of this section, it is a neoplasm that 
has not started from the same causes as excite inflammation, but from 
others that are unknown or but vaguely suspected ; the process in the 
organism (local or general) that produces tumors is generally con- 
sidered different from inflammation ; some regard the two processes. as 
antagonistic to a certain extent (we shall not here discuss the correct- 
ness of this view). If in any given case we have to admit that fac- 
tors which generally cause inflammation (traumatic, thermic, chemical 
irritation, etc.) have not caused the development of the tumor, the 
case seems so unusual that we are disposed to regard the growth as an 
unusual organism. This pathologic or physiological view, as I might 
term it, was not formerly maintained, but I do not think I err in stat- 
ing that, consciously or unconsciously, it is held by most pathologists. 
All writers on tumors, as much as possible, avoid speaking on this 
point, as there is nothing more to say on it ; for we do not know how 
or where we shall draw the dividing line between chronic inflamma- 
tion and development of tumors. So it is not possible to have a 
purely anatomical idea of " tumors," any more than it is of the term 
" typhus ; " to understand them we must make a compromise between 
etiology and pathological anatomy. The etiological expression, " the 
process by which tumors are developed," implies that the fate of the 
product or tumor will probably differ from that of the " inflammatory 
neoplasia ; " hence we might say of tumors that they do not bear in 
themselves the conditions for a typical termination, as do the inflam- 
matory neoplasiae. I would not assert the inflammatory process is at 
all the opposite of that by which tumors are developed ; on the con- 
trary, I believe that observation teaches that, in some cases, the two 
processes correspond, especially in some forms of chronic inflammation 
and sarcoma, while, on the other hand, acute metritis and fibroid of 
the uterus are far enough apart, etiologically and anatomically. The 
idea that the development of tumors has certain specific causes, both 
in or external to the organism, is little disputed ; and, when it is, it is 
hardly in earnest. Virchow asserts that the development of tumors 
may start from an increase of the inflammatory diathesis ; thus, polypi 



ETIOLOGY OF TUMORS. 605 

of the mucous membranes result from long-continued catarrh ; syphilis 
induces, first, inflammations ; then, tumors. I would incidentally re- 
mark that I do not consider any product of syphilis a tumor; a gummy 
nodule or a caseous nodule, caused by syphilis, either heals by reab- 
sorption, or, after being slit up, by suppurating and cicatrizing, while 
in an incised tumor this is exceedingly rare. H. Jleekle von Hems- 
bach advanced the opposite idea, e. g., he says enchondroma of the 
finger is the mildest expression of a scrofulous diathesis. If we com- 
pare the products of inflammation with the histologically more devel- 
oped tumors, it must be acknowledged that, as being the more slowly 
developed neoplasias, tumors are probably due to a feebler local irri- 
tation, more allied to normal growth. All these considerations apply 
only to true growths. In what follows we shall treat of these alone. 
When Virchow classes encapsulated extravasations of blood and 
dropsies of serous sacs among the tumors, he goes beyond our pres- 
ent views. 



LECTURE XLV. 

Etiology of Tumors ; Miasmatic Influence.— Specific Infection. — Specific Eeaction of 
the Irritated Tissues ; its Cause is always constitutional. — Internal Irritations ; 
Hypotheses as to the Character and Mode of the Irritant Action. — Course and 
Prognosis : Solitary, Multiple, Infectious Tumors. — Dyscrasia. — Treatment. — Prin- 
ciples of the Classification of Tumors. 

Let us now go more minutely into the etiology of tumors. Here 
we should propose to find the differences and points of resemblance 
between the processes causing inflammatory neoplasias and tumors. 
Let us start with the causes of inflammation, and compare them with 
those of tumors. Many acute inflammatory processes (exanthemata, 
typhus, etc.), and some chronic ones (intermittents, scorbutus, etc.), 
are due to miasmata and contagions, which enter the body from with- 
out. I do not know any acute miasmatic tumors ; but goitre must be 
considered as a chronic endemic-miasmatic tumor ; goitre cannot be 
regarded as a product of inflammation, as it never spontaneously ret- 
rogrades, suppurates, or shrinks up into a cicatrix ; the cause is a spe- 
cific external one, to which every one, especially the young, is occa- 
sionally exposed, who comes into a country where goitre is endemic ; 
all are not equally disposed to it, there may be an hereditary tendency ; 
infection probably occurs through the blood ; at least, we cannot well 
imagine how the thyroid gland should be infected by local infection. 
Hence goitre is probably the local expression of a general infection, 
which occasionally evinces itself in the whole nutritive state, espe- 



606 TUMORS. 

cially in anomalous development of the skeleton and its results (cre- 
tinism). We may also consider leontiasis and Oriental elephantiasis 
as chronic miasmatic infections, in which large masses of nodular 
fibrous tumors form in the skin on different parts of the body ; still, I 
acknowledge that this is disputed territory, and that reasons may be 
advanced for classing these among the chronic inflammatory diseases, 
instead of among tumors. As regards local infection, or the transfer 
of fixed contagions from without, we know that inflammations of va- 
rious kinds may be thus induced. By putrid substances only inflam- 
mations are induced ; here I class, also, the so-called " dissecting 
tubercle," which I cannot consider as a tumor, because it disappears 
spontaneously, as soon as new infection ceases to occur. Inflamma- 
tion is excited by inoculation with pus; the character of the pus 
determines the specific nature of the inflammation ; pus may also ex- 
cite a constitutional disease, which again may evince itself by multiple 
localized processes, as in syphilis. Can tumors be induced by inocu- 
lation with the juices of tumors, or with small portions of them? 
This is a disputed point ; I consider it possible, but not proved ; the 
difficulty of coming to a decision lies in the fact that it is not allowable 
to make such experiments on men. When such experiments often 
fail on the lower animals, it only shows that tumors from man are not 
transferable to them ; tumors from beasts must be inoculated on beasts 
of like species ; a few such experiments have been made by Doutrele- 
po?it, in which the inoculations of carcinoma from dogs on dogs had 
no effect. At all events, we cannot induce a tumor by inoculating 
with pus, which again seems to show the specific difference of the 
products. Perhaps some pathologists may here answer that " molus- 
cum contagiosum " is an example of tumor-juice or constituents of 
tumors being inoculable on other persons. This fact, which has been 
proved by Ebert and Virchow, is very interesting ; still, the right 
of moluscum contagiosum, a cystoid secretion-hyperplasia of the 
sebaceous glands, a sort of large comedones, as well as that of re- 
tention-cysts generally, to a position among tumors is disputed ; and, 
moreover, the contagiousness of this neoplasia is still too isolated 
for us to draw any valuable conclusions from it. The most striking 
proof of the distinctness of inflammatory products and tumors is 
offered by observation pf the local and general infection, which we 
have innumerable opportunities of making. We have previously 
said a good deal about progressive and secondary inflammation of 
acute lymphangitis, which is always secondary (deuteropathic, ~Vir- 
chow), of the secondary acute and chronic swellings of the lym- 
phatic glands in acute and chronic inflammations, especially of 
the extremities ; I then told you that I considered it more prob- 



ETIOLOGY OF TUMORS. G07 

able that cellular elements from the focus of inflammation passed into 
the lymphatic glands, and, by their specific phlogogenous action, in- 
duced inflammation in the glands, which were analogous to the 
primary peripheral inflammations ; tumors never develop through such 
local infections from inflammatory foci ; if the primary inflammatory 
focus be removed, the swellings of the lymphatic glands also disappear. 
Similar infectious peculiarities also occur in many tumors, especially 
those which, like the inflammatory neoplasia, are very rich in cells; 
not only may the immediate vicinity be infected, and numerous new 
foci be formed immediately around the first nodule, but very often the 
lymphatic glands are also affected, and secondary tumors form in them, 
which have the same peculiarities as the primary ; nor are they any 
more apt to disappear spontaneously than the primary, even when the 
latter is removed ; on the contrary, similar tumors then frequently 
appear in other quite remote parts of the body — metastatic tumors. 
Here you again have the analogy with the course of infection in in- 
flammation, as well as the specific distinction, for metastatic growths 
never result from phlogistic infection, any more than metastatic ab- 
scesses in internal organs do from infection by a tumor. Infection is 
not common to all tumors, although, unfortunately, the majority are 
infectious ; these are called malignant, in contradistinction to the 
benign, or non-infectious. It is difficult to say on what this difference 
is based ; it is probably partly due to the nature and specific charac- 
ter of the element, in their easy mobility, and in the fact that, like 
the seed of some of the lower plants, they find almost everywhere soil 
suited for their development, and can grow in most tissues of the 
body ; probably it is also partly due to the fact that the conditions 
are more or less favorable to the entrance of the elements of the 
tumor into the lymph or blood-vessels ; for instance, it is remarkable 
that frequently very soft tumors (medullary sarcoma) consisting almost 
entirely of cells, when surrounded by a firm connective-tissue capsule, 
cause no infection of the lymphatic glands ; we notice the same thing 
in some large encapsulated abscesses. In regard to metastatic ab- 
scesses, I have already told you that, according to my view, they are 
due to embolism ; we should have to seek another explanation of 
diffuse metastatic inflammations. Diffuse metastatic tumors are very 
rare ; I should apply this term only to a few forms of pleural and 
peritoneal carcinoma or sarcoma. As regards the mode of origin of 
metastatic tumors, the actual course of the infection, from analogy, it 
seems very probable that they, like the secondary tumors of the lym- 
phatic glands, are induced by seed from the primary tumors, or from 
the tumors in the lymphatic glands. I acknowledge I am much in- 
clined to this supposition. Although I could not formerly believe that 



608 TUMORS. 

the cells from a focus of inflammation or from a tumor could be as in- 
dependent as thistle-down, still, I think that, with our present knowl- 
edge about the independent life of pathologically-neoplastic cells, 
there can be no doubt of the possibility of such a process. Quite re- 
cently an observation has been published which is a new proof of the 
great independence of the cells of the rete Malpighii ; I mean the epi- 
dermis transplantation of Heverdin, which has been so often men- 
tioned. This renders it even more probable than formerly that detached 
cellular elements of a neoplasm, carried to some other part of the body 
by the blood or other fluids, may there continue its growth. Although, 
on the first development of a tumor, as on the occurrence of an in- 
flammatory new formation, the lymphatic vessels are partly closed, 
and may be filled with cells, still, subsequently, from compression, 
lymphatic and vascular thrombi may form, into which specific tumor- 
elements enter, and small particles of thrombi, which might form 
during the softening of the tumor, may enter the circulation, become 
attached at different places, and form new tumors. In veins, the for- 
mation of such thrombi filled with specific tumor-elements has actually 
been observed, and, at the same time, analogous tumors have been 
found in the branches of the. pulmonary artery. It is important to 
remember that metastatic tumors, like metastatic abscesses, are chiefly 
found in the lungs and liver, except in cases where direct metastasis 
is very easy, as in pleural tumors, which develop as a result of primary 
mammary tumors, as in hepatic tumors found with those of the intes- 
tines or stomach ; in these cases a direct wandering of tissue-elements 
through the lymphatic vessels is very possible. On this point there 
is still much room for investigation, which, I think, will meet great 
results. As we have already seen, the products of acute inflamma- 
tion mostly have a pyrogenous action ; those of chronic inflammation 
lack this peculiarity almost as much as do those of tumors ; fever 
only occurs in the latter when there is disintegration of the neoplasia, 
and the products of the disintegration enter the circulation; more 
frequently, infection with such excreted matters shows itself in chronic 
inflammation in tumors by a general cachectic state, especially by dis- 
turbance of the general nutrition. 

If we consider what has been said about the contagiousness of 
tumors, we see that there is some probability of their transfer from 
one person to another, though it is not proved ; but there can be no 
doubt that the lymphatic glands and other organs may be gradually 
infected by various kinds of tumors. 

As regards the effect of taking cold locally and generally as a 
cause of inflammation, there are no observations which would justify 
us in referring tumors to a similar cause. I do not know that any one 
has ever asserted and proved that tumors result from catching cold. 



ETIOLOGY OF TUMORS. 609 

Views vary greatly about mechanical and chemical influences as 
causes of tumors. Various as the irritations may be, and much as 
they have been experimented with, in no single case has a tumor been 
caused intentionally by mechanical or chemical irritation ; inflamma- 
tory new formations thus developed do not long outlast the external 
irritation. Wherever and however we apply such mechanical and 
chemical irritants, we only induce inflammations ; if there be any spe- 
cific mechanical and chemical irritation (I mean one acting on the or- 
ganism from without, not starting from the tumor), i. e., one from 
whose action a tumor must develop, it is at present unknown. Then 
the question arises whether there are any reasons which render it 
absolutely necessary to assume such mechanical and chemical irrita- 
tion outside of the organism. I cannot agree to this. It is true there 
are many cases where a tumor forms after a blow, kick, or injury, but 
the number of such cases is very small in proportion to those where, 
after similar causes, there is acute traumatic inflammation, with a typi- 
cal course, or, if the irritation be continued, chronic inflammation also 
with typical course. We must regard this also as a rule : if a porter 
gets a thickening of the skin, with new mucous bursa under it, on the 
spinous process, or if he gets an ulcer at the same point, it is to some 
extent a normal result, they are products of a chronic inflammatory 
irritation, and disappear as soon as the irritation ceases ; but if from 
the same causes a person gets a fatty tumor, which does not disap- 
pear, but even continues to grow when the irritation ceases, we can- 
not here regard the irritation as specific, but must seek the peculiarity 
in the affected part. Previously in general and local infections we 
recognized the specific effects of irritation, now we must also acknowl- 
edge that there is a specific, qualitative, abnormal reaction of the tis- 
sue. Virchow and 0. Weber especially have maintained that exter- 
nal irritation always plays an important role in the development of 
tumors ; this follows undoubtedly from the fact that primary tumors 
are most frequent at points most subject to external irritation. Sta- 
tistics show that the most frequent seat of tumors is the stomach, 
then the portio vaginalis uteri, then face and lips, then the mammary 
glands, rectum, etc. But the reason for the development of tumors, 
and not of chronic inflammation in such cases, must be a specific dis- 
position of these parts in certain persons. Individuals who drink 
much spirits usually have gastric catarrh ; if, among one thousand 
topers, one or even ten, instead of catarrh, had cancer of the stomach, 
he should be considered as an abnormal subject, when compared with 
the mass who do not have it. Up to this point I agree entirely with 
Vtrchoio, who speaks as follows : " Although I cannot tell in what 
particular way an irritation must occur, to induce a tumor in some 
39 



610 TUMORS. 

given case, while in another case, perhaps under apparently similar 
circumstances, it merely excites simple inflammation, still I have com- 
municated a series of facts which teach that, in the anatomical compo- 
sition of different parts, certain continuous disturbances may exist 
which interfere with the occurrence of regulating processes, and 
which, from an irritation that at another spot would have induced a 
simple inflammation, excite an irritation from which the specific tumor 
is developed." Among facts " which teach that, in the anatomical com- 
position of different parts, certain continuous disturbances may exist " 
which dispose to development of tumors, Virchow mentions advanced 
age. It is perfectly true that certain forms of tumors are very fre- 
quently found on particular parts of the body in old persons, e. g., can- 
cer of the lip. Thiersch calls attention to the fact that in the lips of 
old men the connective tissue is often so much atrophied that the epi- 
thelial tissues (sebaceous, sweat, and mucous glands, hair-follicles, etc.) 
become very prominent, and, as it were, receive the preponderance of 
nutrition ; that hence irritation shows itself chiefly in the proliferation 
of these epithelial formations, and that this explains the frequent oc- 
currence of epithelial cancer in the lips of old men. I fully recognize 
the shrewd combination of these observations, but I must add that 
advanced age is just as much a general as a local peculiarity of the 
body, It is also stated by Virchow that places which have been the 
seat of an inflammatory disease, which has left the part weakened, 
also cicatrices, furnish foci for the development of tumors. This is 
undoubtedly true ; but if we compare the innumerable cases where 
simple chronic inflammation occurs in parts that have been acutely 
diseased, and where simple ulceration occurs in cicatrices, the cases in 
which tumors occur at such points appear very small, and it must be 
acknowledged that in these few cases we may assume a specific pre- 
disposition which leads to formation of tumors. The same holds 
good for the fact that tumors are particularly apt to form in organs 
which complete their formation and development late in life ; here 
Virchow classes the articular ends of the bone (which, however, are 
the seat of tumors much more rarely than of chronic inflammations), 
the mammary glands, the uterus, ovaries, testicles, etc. While fully 
recognizing the exercise of observation and brilliant ideas by which 
it is attempted to prove the purely local disposition to development 
of tumors, I cannot consider the proof as at all convincing, but re- 
main of the opinion that there is just as much a specific predisposition 
to the development of tumors as there is to chronic inflammations, 
with proliferation of the inflammatory new formation, with suppura- 
tion, with caseous degeneration, etc. 

To what has just been said we must add that we cannot always 



ETIOLOGY OF TUMORS. 611 

detect a local external irritation when a tumor is developed any more 
than we can always do so in local disease in a scrofulous patient. 
While referring you to what has been said on the etiology of chronic 
inflammations, I would remark that in regard to primary tumors we 
may assume in many cases that there are also specific, so-called inter- 
nal irritations developing in the body itself. Most pathologists agree 
to this, but they consider the mode of origin and development of 
such irritations as being different. Virchow teaches that the local 
disease must have a local cause, and assumes that at the point of dis- 
ease there are certain local conditions of debility. If this were so, we 
should have to assume a specific local debility for the most different 
disturbances of nutrition and for formation of tumors. Hindfleisch 
speaks very decidedly of internal irritation as follows : " By the 
change of substance in the tissues, certain excretive substances are 
constantly being formed, which must gradually be passed off from the 
tissues and organs in which they form, as well as from the fluids of 
the body at large, in order that the life of the individual may be un- 
disturbed. These bodies have their chemical position between the 
organopoietic bodies on the one hand and the excreted matter of the 
kidneys, skin, and lungs, on the other ; thus they fall into the great 
gap that exists in organic chemistry at this point ; they are different 
for the different tissues, and on this difference depends the variety of 
pathological new formations. If they are transformed and excreted 
normally they collect first at the point of their origin, then in the 
fluids of the body, and this collection is the immediate cause for the 
excitement of that progressive process which begins with multiplica- 
tion of cells in the connective tissue, and ends with the development 
of tubercles, cancer, cancroid, fibroids, lipomata, etc." I can entirely 
agree with this hypothesis, but must add that it seems an error to 
suppose that we here speak chiefly of local processes. The produc- 
tion of bile and urine is also a local process ; for them to be produced 
in such quantities and of such a quality as they are depends not only 
on the glandular organs, but on the entire organism to such an ex- 
tent that we must seek the original causes of the secretion of urine 
and bile not only in the blood, but even more remotely, even in pe- 
culiarities of origin, as far back as Adam, if you please. In the same 
way, I think that the original causes for the local requirements for the 
development of tumors must be sought in specific peculiarities of the 
individual organism ; in the same way we speak of a scrofulous or tu- 
berculous person, meaning the pathological race, as it were, to which 
the individual belongs. 

I must lastly add that the supposition that the cause of disease, 
the irritation inducing the tumor, develops local y, where the tumor 



612 TUMORS. 

afterward forms, is as purely hypothetical as any that has yet been 
advanced. Let us take arthritis as an analogy : Zaleski induced the 
most typical arthritis in a goose by ligating the ureters ; an articular 
disease resulting from disturbance of the function of the kidneys . 
Possibly tumors might just as well develop in any tissue from dis- 
turbance of the hepatic function ! Very many things are possible. 
We know nothing certain on this point, and move entirely in hypoth- 
eses. For my part, I find it just as allowable to assume a diathesis 
here, as in scrofula, arthritis, etc. ; that, partly from unknown, partly 
from known causes of general nutrition and ordinary conditions of 
life, abnormal matters proceed, which have a specific irritant action 
on this or that part of the body, analogous to that of certain drugs. 
Lastly, if to this we add that the diathesis for production of tumor is 
hereditary, although not to such an extent as the chronic inflammatory 
diathesis, the doctrine of weakness localized in certain systems of tis- 
sue, or certain parts of the body, seems entirely untenable. There is 
certainly a local cause for the members of one family having large 
noses ; in proportion to the face, they have grown larger than in other 
men, still the large nose of the father cannot descend directly to the 
son, it can only be inherited from the father through the spermatozoa, 
and there the original cause is to be sought ; all peculiarities that de- 
scend by inheritance are unquestionably to be termed constitutional. 

I have now occupied you some time with reflections which some 
of you may consider very tedious ; they will ask me, Of what use 
are these things in practice ? Then, unfortunately, I must acknowl- 
edge that practice pays little attention to them, because they are so 
hypothetical. Those of you to whom such ideas as we have just 
spoken of do not occur, I advise to pay no further attention to them ; 
not to be obliged to speculate as to the final causes of things is, in 
a certain sense, an enviable quality. 

For convenience, let us comprise, in a few short propositions, what 
we have said regarding the etiology. 

Tumors, like inflammatory neoplasia, result from irritation of the 
tissue ; the difference in the causes lies : 1. In the specific quality of 
the irritation. Infection of healthy tissue about a tumor, neighboring 
lymphatic glands, etc., is considered sufficient proof of this. It is 
supposed that, under some unknown circumstances, this specific irri- 
tan; may be formed locally (Rindfleiscli). I think that, partly as a 
resi lit of hereditary predisposition, partly from a developed tendency, 
tha<t is, where there is a diathesis, we may imagine the formation of 
materials in the fl lids of the body, which shall have a specific irritant 
action on one or Dther tissue. 2. Any, usually an inflammatory, irri- 
tation may excite s i tumor, if the irritated tissue is specifically disposed 



PROGNOSIS AND COURSE OF TUMORS. 613 

for the development of growths. Vtrchow, 0. Weber, Rindfleisch, 
and others, assume that such specific peculiarities are entirely local 
and limited to an accidentally irritated part of the body, or to a cer- 
tain system (bones, skin, muscle, nerves, etc.). I cannot imagine the 
localization of such specific peculiarities ; hence, even with this hypoth- 
esis, it seems probable that the apparent local specific peculiarities 
are due to the intimate relations of the entire organism. 

From this representation you may see that the different views 
only differ in the purely hypothetical part. If I entered into the sub- 
ject more fully than seemed necessary for these lectures, it was be- 
cause this very important branch of general pathology has lately 
been so exhaustively and excellently treated of by Virchow, 0, 
Weber, Rindfleisch, LiXcke, Thiersch, JPlebs, Waldeyer, and others, 
that I considered it necessary to develop more fully those parts of my 
views where I differed from these authors, whose excellent writings I 
cannot too strongly recommend for your study. 



In regard to the prognosis and course of tumors, from what has 
been said you may infer : 1. That they seldom recover spontaneously, 
nor are they accessible to medicines ; and, 2. That they are partly in- 
fectious, partly not so. The latter point is particularly striking to 
unprejudiced observation. There are some tumors which do not re- 
turn after extirpation, and others that not only return in the cicatrix, 
but come in the neighboring lymphatic glands and also in internal or- 
gans, as already remarked. The former have for ages been called 
benignant, the latter malignant or cancerous. This observation is so 
simple that it would seem merely necessary to study exactly the 
peculiarities of one or other form of tumor, to arrive at an accurate 
prognosis. But accurate clinical and anatomical study did not lead 
to this desired simple result of this dualism, but it showed that the 
latter did not exist, that the conditions were more complicated. After 
an exhaustive anatomical study and description of benignant and 
malignant growths, they were examined under the microscope and in 
the retort ; it was thought that the characteristic marks had been 
found now in one point now in another, and soon one discovery after 
another proved erroneous : it was thus shown that an antithesis of 
absolute malignancy and benignancy did not exist in the sense meant, 
and that it was necessary to distinguish not only solitary, multiple, 
and infectious tumors, but that a scale must also be made in the grade 
of infectiousness. We must investigate this more closely. We sail 
a tumor solitary when only one occurs in the body and causes purely 
local symptoms ; they are usually growths consisting of any fullv 



614 TUMORS. 

developed tissue — fibroma, chondroma, osteoma, etc. "We speak of 
multiple tumors when a series of similarly-organized growths occur 
only in one certain system of tissue ; for instance, when numerous 
chondromata occur only on bones, or numerous lipomata only in the 
subcutaneous cellular tissue, or many fibromata only in the skin, etc. 
As generally acknowledged, there is at the same time a predisposition, 
which Virchow regards as purely local, but which, as already stated, 
I must consider constitutional. In general, we may say that all sorts 
of tumors may occur as solitary or multiple, although the latter is 
very rare in some forms of tumors. "We apply the term infectious to 
a tumor which not only grows into the parts around it, infiltrating 
them and thus constantly growing by apposition of new foci, but 
which may also infect the next lymphatic glands and finally other or- 
gans. In this respect there are very great differences : in some tumors 
the infection extends regularly only to the next lymphatic glands 
(carcinoma of the lips and face) ; in other cases from that point 
it extends farther, especially to internal organs (carcinoma of the 
breast) ; lastly, infection of the entire body with metastatic tumors, 
without infections of the lymphatic glands, sometimes occurs (some 
forms of sarcoma). Moreover, the rapidity with which infection fol- 
lows, varies greatly. If we examine the conditions under which in- 
fectious tumors develop, and their anatomical structure, we shall see 
that they occur especially in advanced age, about equally in men and 
women, and particularly often in certain organs ; that the age of child- 
hood is disposed to infectious growths, especially to malignant sar- 
comata, while in youth and the first years of adult age very few tu- 
mors of any kind, and especially few malignant tumors, develop. 
Mode of life, good or bad food, poverty, riches, character, nationality, 
and cultivation, appear to have no special influence on the develop- 
ment of tumors generally ; nor can we recognize any specific influence 
of these powers on infectious tumors. The study of the anatomical 
structure of tumors has been pursued with great zeal of late, and it 
appears that a large number of malignant growths have characteristic 
macroscopic and microscopic peculiarities, but that a correct progno- 
sis cannot always be based on them ; in general we may say that 
they are usually very vascular tissue formations, disposed to ulceration, 
and in their course proving to be infectious. As it is most probable 
that the infection results from the locomotion of specific tumor-ele- 
ments, some of the factors relative to reabsorption may here have 
some effect. The quantity of blood and lymphatic vessels in the 
tumor and its immediate vicinity, the conditions influencing opening 
and closure of these passages, and the activity of the circulation gen- 
erally, are to be considered. 



TREATMENT OF TUMORS. . 615 

Infectious tumors are usually at first solitary, very seldom multiple in 
the sense above indicated. Tumors that are multiple from the start are 
rarely infectious. When we use the terms dangerous, malignant, and 
infectious, as synonymous, we do so without regard to the locality 
where the tumors are developed. A solitary benignant tumor in the 
brain is always malignant, from its locality ; an infectious tumor at the 
same point possibly never goes beyond local infection, as it soon 
proves fatal. All these things are to be carefully weighed, if we 
would obtain clear ideas on these points. 

Tumors are not always to be termed infectious (malignant, cancer- 
ous) because of a return at the point of operation. In this case it is 
very important to decide whether the recurring tumor has started 
from portions of the original tumor, that have been left at the time 
of operation (continuous recurrence, Thiersch) , or, possibly years after 
a perfect operation, a new tumor has occurred from similar causes in 
the cicatrix or in its vicinity (regional recurrence). If the point of 
operation remains free, and, after the operation, swellings of the lym- 
phatic glands, of the same nature as the extirpated tumor, appear, or 
if, under similar circumstances, without swelling of the lymphatic 
glands, growths occur in other organs, it may be considered certain 
that these lymphatic glands and other organs were already infected 
at the time of operation, although this may not have been susceptible 
of proof on examination. 

When a person is infected from a tumor, we term it a dyscrasia, 
just as we do when one is infected from a focus of inflammation. In 
such persons foreign materials circulate in the fluids of the body, 
inducing in them a pathological condition. In infectious tumors this 
dyscrasia displays itself by general disturbance of the nutrition — ema- 
ciation, marasmus ; how soon and how extensively this shall occur 
depends very essentially on the seat of the tumor and its peculiarities 
(softening, becoming gangrenous, ulceration, bleeding, etc.) as well 
as on the strength and age of the patient. 



About the treatment of tumors in general I shall here merely 
mention that they are only curable by removal from the body, whether 
by the knife, ligature, ecraseur, caustic, or any other means. The 
removal of intense and rapidly-infecting tumors is usually merely a 
means of prolonging life or of alleviating the sufferings of the patient ; 
tumors that cannot be operated on we can only treat symptomati- 
cally, to ease the patient. I shall speak of the indications for opera- 
ting when treating of the different forms of tumors. 



616 



TUMORS. 



Now, when passing to the consideration of the different forms of 
tumors, we shrink from the mass of material before us. We require 
a leading principle to enable us to arrange the various forms of tumors 
which differ so much anatomically and clinically, and to consider them 
in their relations to each other and to the organism at large. The 
principles on which tumors have been classed have for ages been just 
as different as those on which diseases generally have been and are 
still divided. None of the classifications of disease proposed so far 
have held their place long. Medicine is now taught in various groups 
of smaller systems, and the principles for forming such groups are 
chosen for various reasons. Before pathological anatomy was de- 
veloped, some prominent symptom was taken ; hence we still have in 
medicine the terms icterus, apoplexy, etc., to denote certain diseases ; 
in the same way, as you know, we have tumors designated " polypus, 
scirrhus, lupus, fungus, carcinoma," etc. As soon as the symptoms 
icterus and apoplexy were analyzed and found to depend on very 
different anatomical causes, these terms were banished and replaced 
by others denoting the anatomical condition. The pathologico-ana- 
tomical arrangement of disease, as proposed by JRoikitansJcy, for in- 
stance, is undoubtedly scientific, as is the system of general pathology 
of Virchow ; still, neither of them is accepted without reserve by 
clinical teachers. It was desired to divide diseases according to their 
peculiar nature and cause ; but Schonbeirts attempt to found a system 
with this idea failed, for our knowledge of the causes and nature of 
disease is not sufficient fully to carry out the plan. What, then, is to 
be done ? Practical medicine and surgery start partly from the ana- 
tomical system, consider this as generally known, and use it for sub- 
dividing more extended descriptions of disease founded on an etiolo- 
gical, prognostic, symptomatological, or physiological basis. It would 
certainly not be unscientific even now to write a monograph on icterus 
or apoplexy — then the anatomical conditions would come in the second 
rank ; pathological anatomy is used as any other aid to science, as chem- 
istry, physics, etc. ; we always try to bear in mind that the object in 
fathoming the whole process of disease lies not in simply fathoming 
the morphological conditions ; it is desirable to understand not only 
the anatomical change, but also the mode and causes of the physiologi- 
cal disturbances. It would be decidedly unscientific in typhus, even 
if a number of palpable changes were found, to admit nothing except 
the peculiar intestinal inflammation ; we may regard this as something 
of the past. Could we group all diseases from an etiological point of 
view, it would be an immense advance ; then pathological physiology 
would take the place of pathological morphology, while with our 
present knowledge we are quite proud if we accurately recognize the 



CLASSIFICATION OF TUMORS. G17 

morphological development of the morbid product, for we can then 
say that we know at least one important factor of the pathological 
process. In fact, we know no more about normal development ; it will 
be long before we understand the physiology of the growing foetus. 

After these considerations, we may not be any more particular 
about the classification of tumors than we are in the other diseases ; 
we must see that there will be a difference according as we choose 
etiology, symptomatology, prognosis, or anatomy, as the principle for 
division. Formerly, surgeons preferred classing tumors according to 
the prognosis of the individual forms, into malignant and benignant, 
and adding a few subdivisions according to the appearance or con- 
sistence of the tumor or the looks of its cut surface. This was enough 
as long as observations on these subjects were made in the gross, and 
the surgeon made no great claims in prognosis. But the more accu- 
rate the observations at the bedside, and the more varied the forms 
in which the neoplastic tissue appeared under the microscope, the 
more impossible it became to make the anatomical peculiarities of 
tumors agree with the old views of malignancy and benignancy. 
While now most surgeons and pathological anatomists gave up the 
idea of letting the prognosis play a part in the classification, and since 
Johannes Mullens works on this subject turned their attention to 
working out the finer anatomy and developmental layers of the 
pseudo-plasms, I still made some attempts to retain the clinically- 
prominent symptoms of benignancy and malignancy in a more en- 
larged form, as a basis for the classification of tumors, and under 
these to arrange the modern acquisitions of pathological histology. 
Either I did not find the correct form and expressions for my ideas, or 
the task I tried was impossible, for I remained alone with my ideas on 
this subject, and have abandoned them. Although I am still of the 
opinion that we should not cease seeking for a pin T siological (etio- 
logical-prognostic, clinical), recognition of the process on which the 
formation of tumors depends, and although I should even now esteem 
a division of tumors on physiological-genetic principles more highly 
than one on anatomical-genetic principles (which was Virchoic^s idea 
in his wonderful classic work on tumors), still I abandon further at- 
tempts in this direction, and follow the anatomical principles in clas- 
sification, passing gradually from tumors formed of simple tissues to 
those formed of more complicated tissues. 

Lastly, I must mention that I voluntarily and intentionally limit 
my lectures to those cases of tumors which, in the commencement of 
the disease at least, are seated in parts of the body belonging to sur- 
gery. This limitation is not so important as it seems ; we may even 
say that the peculiar course of tumors can only be studied in its 



618 TUMORS. 

purity, when they are located in parts where they do not directly 
endanger life; for the symptoms which they cause when in liver, 
stomach, or brain, are not those due to the tumors themselves, but are 
chiefly disturbances of function in the affected organ. If every typhus 
was accompanied oy fatal intestinal haemorrhage or perforation of the 
intestine, we should never have a pure representation of the disease 
proper, as its course would always be disturbed. We shall here and 
there remark on the relative frequency of primary localization of tu- 
mors in the internal organs, but cannot go into the symptomatology 
and histology of the diseased organ. On these points you will be 
instructed by the pathological anatomists and in the medical clinic. 



LECTURE XLVI. 

1. Fibromata : a, Soft ; b, Hard Fibroma. — Mode of Occurrence ; Operations ; Ligature ; 
Ecrasement ; Galvano-caustic. — 2. Lipomata : Anatomy ; Occurrence ; Course. 
3. Chondromata: Occurrence; Operation.— 4. Osteomata: Forms; Operation. 

1. FIBEOMA— FIBEOUS TTTMOE— CONNECTIVE-TISSUE TUMOE. " 

Tumors composed chiefly of developed connective tissue are 
called fibromata. They occur in the following forms : a. Soft fibrous 
or connective-tissue tumors. These are quite frequent, and are located 
almost exclusively in the cutis ; they are composed of a very tough, 
somewhat cedematous, white tissue, and are usually covered by the 
thin papillary layer of the cutis. Microscopic examination shows 
loose connective tissue, as in the cutis. On the surface of the tumor 
there are almost always pointed papilla?, even when the tumor is de- 
veloped in a part of the skin which normally has no papillae; in the 
rete Malpighii of these formations, there is often a brownish pigment, 
which rarely extends deeper in the tissue ; they may also have large 
vessels and abnormal enlargements of the hair and sweat glands on 
their surface ; they are usually loosely hanging (cutis pendula, molus- 
cum fibrosum), often distinctly pedunculated tumors ; they might be 
termed partial hyperplasias of the skin, as they consist essentially of 
the elements of the skin. The growth is very slow, free from pain, and 
often goes on to the development of enormous tumors. Occasionally 
such growths are congenital ; they may be multiple ; hundreds of them 
may occur on the surface of the body. The congenital cutis-prolifera- 
tion is most frequent on the face, generally unilateral, diffuse or in the 
shape of soft, cock's-comb-like vegetations. Freckles, pigmented hairp- 
in other's-marks (moles, benignant melanoses, melanoma, pigmented 



FIBROMATA. 



619 



fibroma) belong to this class. These tumors are apt to occur toward 
the end of middle life ; in women, we not unfrequently find them 
hanging from the labia majora ; as growths on this part are concealed 
as long as possible, they are usually quite large when first seen by the 
surgeon. Virchow terms the disease, in which these multiple, soft, 
fibrous tumors develop, leontiasis / in the course of time they are 
occasionally accompanied by general disturbances of nutrition. Al- 
though these tumors are not infectious, in the meaning we have at- 
tributed to this word, they occasionally lead to a cachectic state, and 
in the course of years to death by marasmus. There is also a relation- 
ship between this disease and Oriental elephantiasis, although by this 
name we mean a more nodular, but at the same time rather diffuse 
hypertrophy of the cutis of certain parts of the body (labia pudenda, 
scrotum, legs), which runs its course with repeated erysipelas. There 
would be less misunderstanding if these developments were briefly 
termed hypertrophy of the skin or pachydermata. Elephantiasis 
Grascorum is a similar disease as far as regards the cutaneous thick- 
ening, but it is strongly endemic, and is accompanied by some ner- 
vous symptoms ; it occurs in Greece, Asia, and Norway (under the 
name of Spedalsked), and, after inducing long suffering, usually proves 
fatal. 

b. Firm fibromata, fibroid, des- 
moid tumors appear to the naked 
eye to be composed of very firm, 
closely - interlaced fibrous tissue. 
They are always very hard, and of 
roundish or tuberous form; their 
cut surface is pure white, or pale 
reddish; to the naked eye many 
of them show on their cut surface 
a very peculiar, regular layering, 
and a concentric arrangement of 
filaments around distinct axes (see 
Fig. 115) ; according to my investi- 
gations, this results from the fibrous Sma " 1B ^SS^X'JS& ™™ : 
formation taking place around 

nerves and vessels, the latter being consequently embedded in the 
midst of the fibrous layers ; frequently the nerves are thus destroyed. 

With the external peculiarities just described, the histological ap- 
pearance renders it difficult to classify these tumors. There can be no 
doubt that those of them which consist chiefly of connective tissue, 
such as old uterine fibroids, should be called fibromata; but the 
younger tumors of this variety, with the same appearance and con 



Fig 115. 




620 



TUMORS. 



sistence, show little connective-tissue but numerous spindle-shaped 
cells. The significance of these cells is varied. Virchow considers 
them muscle-cells ; hence, what have hitherto been called fibroids of 
the uterus, he does not class among the fibromata, but among myo- 
mata, and terms them " myoma lsevicellulare." If we consider fibre- 
cells as young connective tissue, we must christen these tumors 
spindle-celled sarcoma or fibro-sarcoma. You see here, in apparently 
simple fibrous tissues, we become involved in difficulties with histology 
and histogeny. There are two things that would induce me to regarde 
fibro-cellular tumors as myomata : i. e., the oval and finally rod-like, 
wavy form of the nuclei, and the very distinct arrangement of the 
fibrous layers into bundles, while the individual fibre-cells are iso- 
lated with difficulty, perhaps only by aid of the recognized chemical 
means. At the same time the soil in which the tumor is developed 
is very important, the probabilities for a myoma would be very great 
if the neoplasia occur in the substance of the uterus. 

Fig. 116. 




From a myo-fibroma of the uterus. Magnified 350 diameters. Oblique and longitudinal section 
of muscular cell-bundles. 



Fibromata are capable of some anatomical metamorphoses. Par- 
tial mucous softening, great serous infiltration (brawny appearance 
and consistence), calcification, and even true ossification, are not very 
rare. Superficial ulceration is quite frequent in fibromata lying close 



FIBROMATA. 



621 



under a mucous membrane ; it results from external injuries in the 
usual way. The ulcer, thus formed, often shows good granulations 
and suppuration, and, under favorable circumstances, it may be brought 
to cicatrize. Fibrous tissue, though apparently poor in vessels, often 
contains quite a number, both of arteries and veins, as may be shown 
by injections ; occasionally a very coarse cavernous net-work of veins 
forms in it (see Fig. 117) ; arteries and veins are so intimately united 
with the tissue of the tumor, that their adventitia mostly disappears 
in it, so that, in case they are injured, they cannot retract either trans- 
versely or longitudinally, and they remain gaping. This is the ana- 



Fig. 117. 
b 




a and 5, vessels of a cutis fibroma (myoma ?) from the thigh, injected through an artery ; 5, cav- 
ernous veins: c, peculiar regularly-arranged, veins of a cutis-fibroma (myo-fibroma ?) of 
the abdominal walls, injected through a vein. Magnified 60 diameters. 



tomical mechanical cause for bleeding from fibromata being so pro- 
fuse, and why frequently it is not arrested without artificial aid. The 
rigid gaping opening of the vessel renders the formation of a thrombus 
very difficult. Occasionally, in large uterine and in periosteal fibro- 
mata, we find lacunar fissures filled with thin serum ; possibly these 
are ectatic pathological newly-formed lymph sinuses ; there are no 
certain observations on this point. Cavities, as large as the head, 
filled with serum, also occur in uterine fibromata (Spencer Wells). 

The localization of fibroma varies greatly ; of all the organs the 
uterus is most frequently affected (if under the general term " fibroid " 
we include myo-fibroma) ; here these tumors occasionallv attain an 



622 



TUMORS. 



enormous size, and then not unfrequently calcify. They are usually 
roundish, and are distinctly and sharply bounded : they are most fre- 
quent in the body of the organ, rarer in the neck, and hardly ever 
occur in the vaginal portion ; their growth progresses upward and 
downward, that is, into the abdomen, gradually stretching the perito- 
naeum, or through the os uteri into the vagina. In the latter direction 
the tumors continue to grow, become pedunculated, and often give 
rise to severe haemorrhages ; they are called Jlbrous uterine polypi. 

Fibromata, starting from the periosteum, are quite frequent ; they 
are almost always fibro-sarcomata, i. e., they are composed of fibres 
and spindle-shaped cells, the latter may even preponderate (fibrous 
sarcoma, MoJcitansky). The periosteum of the bones of the skull and 
face is particularly liable to this disease, especially the inferior turbi- 
nated bone ; from this point fibromata project into the nasal cavities 
and fauces as polypous growths (fibrous naso-pharyngeal polypi) ; 
by pressure they may cause reabsorption of the bone and grow into 
the cranium or antrum Highmori ; they are particularly vascular. J 
have also seen fibromata on the periosteum of the tibia and clavicle, and 
in bone itself, as in the upper maxilla, where I have met strange com- 
binations of chondroma and fibroma. Lastly, we have to mention that 
fibromata are not rare in and on the nerves (Fig. 118). Frequently all 
tumors occurring on nerves are called neuromata, but they are distin- 
guished according to their anatomical characteristics ; most neuromata 



Fio. 11& 




Fig. 119. 




Neuroma, after Fdlin 



Small nodular fibro-sarcomatous neu- 
romata from the eyelid of a boy ; 
natural size. 



are fibromata or fibro-sar comata in the nerve-trunks ; others consist 
partly or entirely of newly-formed nerve-filaments (true neuromata). 



FIBROMATA. 623 

Sometimes the nerve-fibromata follow the nerve-trunks and form nod- 
ular cords (plexiform neuromata, Verneuil) (Fig. 118), on whose con- 
fluence, as already stated, the peculiar appearance of the cut surface 
of the fibroma (Fig. 115) occasionally depends. Fibroma is rare in 
the subcutaneous cellular tissue ; in the glands, except, perhaps, in the 
mamma, it hardly ever occurs. 

The fibrous tumors just enumerated are particularly apt to develop 
in middle age (from thirty to fifty years) ; they are rarer in youth, and 
still more rare in advanced age. When we find them in the uterus 
of old women, there will probably have been there many years. Only 
fibroid neuromata, and bone and periosteal fibromata, occur in young 
persons, not exactly in children (though I saw one case of neuro-fibroma 
in a boy seven years old), but usually after puberty. Fibromata 
are somewhat more frequent in women than in men ; uterine fibromata 
develop about the thirty-fifth to the forty-fifth year, although the 
trouble from them is often experienced later ; they are rather more 
frequent multiple than solitary ; periosteal fibromata usually remain 
solitary, but not unfrequently return, though, perhaps, not for years 
(regional recurrence ; relation to sarcoma). Usually the growth of 
fibroma is purely central, and they are not infectious ; but infectious 
fibromata are said to occur. Several such tumors near together unite, 
infiltrate the surrounding parts, and occasionally cause fibroid degen- 
eration of the neighboring muscles, bones, and lymphatic glands. The 
infectious fibromata that I have seen were always fibro-sarcomata ; 
like pure sarcomata, they may appear as metastases in the lungs. 
Fibromatous neuromata are quite frequently multiple, especially in 
different branches of the same nerve. Some time since I extirpated 
six neuromata from one man ; three from the left arm, three from the 
left lower extremity. Cases have been seen where there were twenty 
or thirty neuromata at once. 

Pure fibromata usually grow very slowly, and in age their growth 
is occasionally checked. This is best known of fibroma of the uterus, 
which usually ceases to grow after the change of life, and then often 
becomes calcareous. Combinations with other tissue-formations, es- 
pecially with sarcoma, as already stated, occur, and take place in such 
a way that the primary tumors present a fibrous consistence, while the 
recurring tumors and secondary tumors resulting from infection are 
soft cellular sarcomata. I have seen such cases. A man about twen- 
ty-five years old, of healthy appearance, had a fibro-sarcoma as large 
as a walnut, in the abdominal walls ; it was entirely removed ; a new 
tumor appeared in the wound ; subsequently several soft tumors ap- 
peared at other points on the surface of the body ; at the same time 
the patient became marasmic and died in a few months ; the whole 
lung was filled with soft sarcomatous tumors. 



624 TUMORS. 

After what has been said, the diagnosis of fibroma is not difficult , 
fche consistence, locality, age, mode of attachment, and form of the 
tumor, almost always lead to its correct recognition. 

The treatment consists exclusively in the removal of the tumor. 
When practicable, this is generally done with the knife ; but pedun- 
culated or hanging connective-tissue tumors and fibrous polypi admit 
of other methods of operation. Formerly the ligature was much re- 
sorted to in such cases, i. e., the pedicle of the tumor was tied tightly 
with a thread, so that it became gangrenous and fell off; this method 
was chosen especially in cases where bleeding from the cut surface 
was feared. Ligation has the great disadvantage that then the tumor 
decomposes in or on the body, and that the iigature must be tightened 
several times before it cuts through ; this may induce severe haemor- 
rhage. The ligature may be combined with incision, by cutting off 
the tumor in front of the ligature, and leaving only part of the pedicle 
to become detached spontaneously. In the nares and pharynx, as 
well as in the vagina, there is of course great difficulty in applying a 
ligature, and for this purpose numerous instruments, simple and com- 
plicated, so-called loop-bearers, have been constructed, by means of 
which the ligature is passed over the tumor on to the pedicle. But 
the ligature is now so generally rejected and so little used, that all 
these instruments, some of which are very ingenious, are for the most 
part only of historical value. 

But the desire to remove pedunculated tumors without haemor- 
rhage is still strong, and has lately led to new instruments and new 
methods, which, however, could not have become popular before the 
introduction of chloroform. Crushing and burning off have now 
taken the place of the ligature. ]£crasement as done by Chassaignac 
we have already described ; this operation, if done slowly, is followed 
by no haemorrhage, even from arteries of the diameter of the radial ; 
the resulting wound is perfectly smooth and regular, and heals well 
without much sloughing from the surface ; although haemorrhage is 
not certainly avoided in all cases, it is in most ; the instrument is made 
of various sizes ; the smallest may be passed into the nose, and with 
it we may readily crush off small pedunculated naso-pharyngeal polypi. 
The galvcmo-caustic of Middledorpf 'is a method of similar effect ; its 
object is to heat a loop of platinum wire between the two poles of a 
galvanic battery, and with it burn through the base of the tumor ; the 
result is a simultaneous division and arrest of haemorrhage ; the latter 
fails about as often as it does in ecrasement, that is, very rarely — 
hence this method is advisable in certain cases. The trouble in pre- 
paring a strong, active battery (which is quite expensive) is such that 
galvano-caustic will probably never come into general use ; in spite 
of its elegance, it has been strangled almost at its birth by the intro- 



FIBROMATA, LIPOMATA. 625 

duction of the ecraseur ; the medical public has already decided the 
question ; almost every operating surgeon has an ecraseur, only a few 
hospitals have galvano-caustic apparatuses. 

As regards operation for non-pedunculated, more deeply-seated 
fibromata, some of them are not at all accessible to surgical treat- 
ment; we cannot recommend cutting uterine fibromata out of the 
abdomen, not because the operation is excessively dangerous, but 
because, in the course of time, these tumors usually come to a stand- 
still, and the annoyance they cause rarely balances the danger to life. 
As regards those fibromata, also, which are not dangerous from their 
seat or growth, but to operate on which would be dangerous, we 
should bear in mind that these tumors grow very slowly, often come 
to a halt in advanced life : hence we should not undertake such opera- 
tions too hastily, or urge them too strongly. But there are many 
cases w r here we may and 'must operate without hesitation; extensive, 
frequently-repeated haemorrhages from an ulcerated fibroma, threat- 
ened destruction of bone, or protrusion into the skull, are urgent 
indications. In neuro-fibromata the pain is sometimes so severe that 
the patients strongly urge operation, even if we have to tell them 
that paralysis of the parts supplied by the nerve affected would be 
the necessary result, for we almost always have to excise a portion 
of the diseased nerve which possibly still performs part of its func- 
tions. If the neuroma be painless, it would be foolish to excise it. 

2. LIPOMATA— FATTY TUMORS. 

Of course, the disposition to formation of fat, when it does not 
exceed a certain point, is not regarded as a morbid diathesis, but 
rather as a sign of good nutritive condition, and varies with the age, 
being greatest between the thirtieth and fiftieth year, and being es- 
sentially favored by a quiet, pleasant life and phlegmatic disposition. 
We only begin to regard it as a disease when it induces functional 
disturbance of different organs, or of the organism at large, or if the 
development of fat be limited to a small part of the body, when it 
appears as a fatty tumor. 

The anatomical formation of fatty tumors is simple ; they consist 
of fatty tissue, which, like the subcutaneous fat, is divided into lobes 
by connective tissue. This connective tissue may be more or less de- 
veloped, and the tumor may consequently be sometimes firm (fibro- 
matous lipoma), sometimes softer (simple lipoma). The shape is 
usually round and lobular, and the fatty mass separated from the ad- 
jacent structures by a thickened layer of connective tissue (circum- 
scribed lipoma, the usual form), and may readily be separated from 
the parts around ; more rarely, lipoma appears as a corpulence limited 
40 



626 TUMORS. 

to one part of the body, as a swelling without distinct boundaries 
(diffuse lipoma). The seat of lipoma is most frequently in the subcu- 
taneous cellular tissue, especially of the trunk; these tumors are most 
frequent on the back and abdominal walls ; they are rarer on the ex- 
tremities ; in the synovial folds and tufts of the joints, as well as in 
the sheaths of the tendons, there may be an abnormal development 
of fat, so that the fatty masses may seem branched like a tree (lipo- 
ma arborescens, J. Mutter) ; this is an analogy to the fatty prolifera- 
tion in the processes of the peritoneum of the colon (appendices 
epiploicag) and other serous membranes, but it is exceedingly rare. 
The growth of lipoma is always very slow, its development is hardly 
ever accompanied by pain, unless it comes close to a nerve and presses 
on it, which rarely happens. Fatty tumors may attain a great size ; 
the patients, being little troubled by them, rarely feel obliged to have 
them removed early. Hence lipomata grow to enormous tumors ; 
recently I removed one from the back of a woman ; it began under 
the right scapula and reached down to the calves ; above, at its base, 
it was the same circumference as the larger part of the patient's thigh, 
below it was almost twice as large. Secondary changes in these tu- 
mors are not very frequent, but the thick connective-tissue partitions 
in the tumor may calcify, or even ossify, and at the same time the fatty 
tissue may change to an oily or emulsion-like fluid. The skin covering 
the tumor is gradually expanded, and at first is usually much thickened, 
and occasionally colored brown, but generally remains movable over the 
tumor ; exceptionally there is an intimate adhesion with the newly- 
formed fat, and then a superficial ulceration of the cutis, which in such 
cases is entirely atrophied ; this ulceration, which may be induced by 
external irritation, rarely goes deep, although parts of the fatty tissue 
may become gangrenous ; under such circumstances there are almost 
always formed ulcers with slightly-developed granulations and serous, 
badly-smelling secretions. Combinations of lipoma with soft fibroma, 
with myxomatous sarcoma, and with lymphoma, do occur, although 
rarely. In lipoma I have several times seen considerable cavernous 
dilatation of the veins. 

A disposition to the development of lipoma most frequently exists 
at the time of life when the tendency to development of fat generally 
is greatest, between the thirtieth and fiftieth years ; in children it is 
very rare, still it occurs congenitally on the back, neck, face, as well as 
on the toes, with coincident hypertrophy of the bones (giant growth) ; 
they grow little after birth. Usually there is only one lipoma, and it 
grows very slowly; indeed, it may remain at one point, especially in 
old persons. In the subcutaneous cellular tissue, development of 
multiple lipoma has been frequently seen ; cases have been noted 



LIPOMATA, CHONDROMATA. 627 

where fifty or more, usually small lipomata, were developed at once ; 
subsequently they ceased to grow. Multiple lipomata are often mixed 
tumors. Simple lipoma is never infectious ; hence it never recurs after 
extirpation. 

Pressure and friction are occasionally observed as exciting causes 
for the development of fatty tumors ; there is also a moderate degree 
of hereditary influence in fatty disease generally. 

The diagnosis of lipoma is generally easy ; the consistence, the 
lobular feel, occasionally a perceptible crackling, from compression of 
individual fat-lobules, are the objective symptoms ; other aids for con- 
firming the diagnosis are, the movability of the tumor, the slow 
growth, age of the patient, and, above all, the region of the body ; 
there is a possibility of mistaking them for fibrous tumors, sarcomata, 
lipomatous-cavernous blood-tumors. 

The treatment consists in removal with the knife. Healing is 
usually preceded by free discharge of gangrenous tissue from the 
wound ; in very large lipomata it is best always to remove a portion of 
the skin covering it, with the tumor ; after their extirpation erysipelas 
is quite frequent, especially in very fat patients. The largest lipomata 
may be removed with good result, as they usually occur in persons 
otherwise healthy. Extirpation of diffuse lipomata is more unfavor- 
able than that of the circumscribed ; the local and general reaction is 
usually more considerable, but I have several times performed such 
operations with good results. 

3. CHONDROMATA— CARTILAGE-TUMORS. 

These are tumors consisting of cartilage, of the hyaline or fibrous 
variety. The microscopic elements of pathological, newly-developed 
cartilage may vary ; occasionally we see exceedingly beautiful round 
cartilage-cells, such as are particularly found in the embryo, and some- 
what smaller in the articular and costal cartilage ; but such a complete 
change of hyaline substance to a homogeneous mass, as is the rule in 
normal cartilage, is more rare in chondromata ; frequently the inter- 
cellular substance pertaining to the different groups of cells is distinct, 
and between the large groups of cells the hyaline substance forms fine 
filaments. The latter is the cause of sections of cartilage-tumors 
having the appearance of being traversed by capsular-like, communi- 
cating connective-tissue meshes, which even to the naked eye show a 
kind of net-work ; the bluish or yellowish glistening cartilage is seen 
embedded between these connective-tissue striae. The tissue of chon- 
droma also distinguishes itself from that of normal cartilage by the 
fact that the former is usually vascular in the above-mentioned 
fibrous striae, while, as is well known, the latter has no vessels. The 



628 



TUMORS. 



microscopic appearances in chondroma have still some other points of 
difference from those of normal cartilage. Not unfrequently the inter- 
cellular substance, whether hyaline or slightly striated, instead of 
having the regular firm consistence of normal cartilage, is more gelat- 
inous or friable, or possibly becomes so secondarily. Calcification of 
the cartilage, as well as true ossification, is quite frequent in chon- 
droma; the forms of the cells may vary greatly (Fig. 120). 

Fig. 120. 




Extraordinary forms of cartilage-tissue from chondromata, taken from men and dogs. 
Magnified 350 diameters. 



In shape, chondromata are usually roundish, nodular, sharply- 
bounded tumors, which may grow to the size of a man's head, or 
larger. At first their growth is almost purely central ; subsequently, 
however, the tumor enlarges, partly from the occurrence of new foci 



CHONDROMATA. 629 

of disease in the immediate vicinity, partly from transformation of the 
adjacent tissue into cartilage (local infection). Among the anatomical 
metamorphoses, the pulpy and mucous softening, and the ossification 
of individual parts, have been already mentioned ; the former causes 
mucous cysts in these tumors, which give a feeling of partial fluctua- 
tion to the otherwise hard chondroma. It is imaginable that, with 
complete ossification of the chondroma, the tumor would cease to 
grow; and this has been seen in some cases, although rarely. In large 
chondromata superficial ulceration is apt to occur, especially if the 
skin is very tense, or from occasional traumatic irritation, but it is of 
no great importance. Ulcerative central softening and perforation 
outwardly are rare, but once I saw it occur in a typical chondroma, 
the size of a large apple, on the sheath of one of the tendons of the 
foot. 

Virchow calls the ossifying cell-layer between the periosteum and 
growing bone, osteoid cartilage ; hence he terms periosteal and ossi- 
fying tumors, which have a formation similar to this osteoid cartilage, 
" osteoid chondromata." I am doubtful about any one being able to 
distinguish such tumors, which I have often examined, from periosteal 
ossifying round-celled or spindle-celled sarcomata ; hence I prefer not 
separating Virehoiv's osteoid chondroma from the sarcomata. 

Occurrence. Cartilage-tumors are particularly apt to develop on 
the bones. The phalanges of the hand and the metacarpal bones are 
the most frequent seat of chondromata ; much more rarely the analo- 
gous bones of the foot. On the hand, chondromata are almost always 
multiple ; they even occur in such numbers that scarcely a finger re- 
mains free from them. The bones next most liable are the femur 
and pelvis ; here the tumors attain the largest size, and lead to com- 
plete destruction of these bones. Chondromata are rarer on the 
bones of the face and skull, but somewhat more frequent on the ribs 
and scapula. They occasionally, but rarely, develop in the sheaths 
of the tendons. In the soft parts also, especially in the glands (tes- 
ticles, ovaries, mammae, salivary glands, etc.), cartilaginous growths 
have been observed, sometimes in the shape of fully-developed chon- 
droma, sometimes as single pieces of cartilage, with a predominance 
of sarcomatous or carcinomatous growth. 

The development of chondroma is chiefly peculiar to youth ; not 
that it occurs exactly in children, but shortly before the age of pu- 
berty. Most chondromata are referable to this age, even if they are 
first recognized much later in life. The tumors occasionally develop 
after injury, grow very slowly for twenty or thirty years, and occa- 
sionally seem to cease growing entirely. I have heard patients as- 
sert that the tumors had remained unchanged for years, and some ac- 



630 



TUMORS. 



cidental cause made them desirous of having them removed. Some- 
times they grow more rapidly and become infectious ; cases are 
known where cartilaginous tumors have appeared even in the lungs 
(embolic) and caused death. 0. Weber has also observed an hereditary 
chondromal diathesis. In the combinations of cartilage-formations 
with sarcoma or carcinoma, the former has no effect on the prognosis 
of the tumor as a whole. 

Fig. 121. 




Chondroma of the fingers. 



The diagnosis and prognosis may readily be inferred from what 
"has been said. We must only add that the softened and cystoid 
forms of chondroma often figure in old works under the names col- 
loid tumors, gelatinous cancer, alveolar cancer, etc. As the epithe- 






CHONDROMATA, OSTEOMATA. 631 

lial elements and connective-tissue framework may become gelatinous 
(mucous, colloid, myxomatous) in fibroma, chondroma, and sarcoma, 
as well as in adenoma and glandular cancer, w T e must always ob- 
serve very particularly what w 7 e have before us : frequently we shall 
be in doubt about the significance of the histological elements, as 
well as about the proper name. 

The only treatment is removal of the tumor, if it can be done 
without endangering life. Of course we would not interfere with the 
chondromata of the pelvis, which are usually very large ; those of the 
thigh, which are generally very large when the patient applies for 
treatment, can only be gotten rid of by exarticulation of the femur, 
and we should scarcely do this before spontaneous fracture of the 
extremity, from disease of the bone, has rendered it useless. Chon- 
dromata of the fingers are most frequently subjects for operation, not 
because they are painful, -for they are usually free from j:>ain, but be- 
cause they impair the function ; this takes place very slowly and 
gradually, hence the tumors will have attained a considerable size. 
So long as the patients can use their nodulated swollen fingers, they 
neither urge the operation, nor can we urgently advise them to sub- 
mit to it. As regards the mode of operation, in many cases where 
the tumor, even if firmly adherent to the bone, is seated laterally, it 
would be natural to try dividing the skin, and pushing it and the 
tendons to one side, then removing the tumor with the knife or saw. 
But this is rarely practicable, if we would remove the entire tumor, 
which is imperatively necessary ; for often the cartilaginous mass en- 
tirely pervades the medullary cavity of the bone. Moreover, after 
such an operation, there may be severe inflammation of the sheath of 
the tendon, as a result of w*hich the finger may remain stiff. There 
have not been enough careful observations to verify DieffenbacNs 
assertion, that any remnants of the chondroma that may be left ossify 
and become stable; hence the removal of chondroma from bone 
should be limited to few cases, and to those where the tumor is still 
small. If the tumors have attained a considerable size, we postpone 
exarticulation of the fingers to a time when the tumors shall have 
rendered the hand entirely useless. 



4. OSTEOMATA— EXOSTOSES. 

By this term we designate abnormally-formed masses of bone, 
which are circumscribed, and have an independent growth, not de- 
pending on a chronic inflammation. Formation of bone also occurs 
occasionally in other tumors, especially in those forming in bone, as 



C32 



TUMORS. 



we have already remarked when speaking of chondroma. But the 
name osteoma is usually limited to- tumors consisting entirely of bone. 
I may mention here that not only new formations of entire teeth 



Fig. 122. 







Odontoma of a back tooth, 
natural size. 




Section of an odontoma. Magnified 100 diameters. 



(very irregularly shaped) occur in ovarian cysts and in the antrum 
Highmori, but that on the teeth themselves outgrowths of true ivory 
matter, ivory exostoses (odontoma of Virchow) have been observed ; 
but these are very rare, and may be regarded merely as curiosities. 
Exostoses consist partly of spongy bone-substance, like that in the 
medullary cavity of bones, partly of ivory-like substance, like that in 
the regular lamellae of the cortical substance of the hollow bones ; 
hence we shall distinguish spongy exostoses and ivory exostoses. A 
third form of osteomata is formed by the ossification of tendons, fas- 
cia3, and muscles, whose right to be classed among tumors is, how- 
ever, doubtful. 

(a.) Spongy exostoses, with cartilaginous covering, (exostosis car- 
tilagina?). These tumors occur almost exclusively on the epiphyses 
of the long bones ; they are outgrowths from the epiphyseal cartilages, 
whence Virchow very properly calls them " Ecchondrosis ossificans" 



OSTEOMATA. 



633 



(Fig. 124). On their roundish, nodular surface, there is a layer of 
beautifully-developed hyaline cartilage, about a line or a line and a 
half thick, which evidently grows partly in itself, partly peripherally 
from the periosteum or perichondrium, then rapidly ossifies toward the 
centre. The newly-formed bony mass itself is, from its start, most 

Fig. 124. 




lH !i 



Pedunculated spongy exostosis from the lower end of the femur, after Pean. 



intimately connected with the spongy substance of the epiphyses, so 
that the hard tumor is immovably seated on the bone. From the na- 
ture of these exostoses they can only occur in young persons. Ac- 
cording to my observation, tibia, fibula, and humerus, are their most 
frequent seat. 

{p.) Ivory exostoses. These consist of compact bony substance, 
with Haversian canals and lamellar systems; they develop on the 
bones of the face and skull (Figs. 125 and 126), on the pelvis, scapula, 
grer-t toe, etc., and form roundish, nodulated, or smooth tumors. 



634 



TUMOES. 



A third variety of tumor-like formation of bone is the abnormal 
ossification of tendons, fasciae, and muscle, which usually occurs on a 



Fig. 125. 




Ivory exostosis of the skull. 



series of tendons and fasciae after they have previously ossified a great 
deal, so that the skeleton of such patients, who are generally young, 



Fig. 126. 



/ 




^ 



s^ 



Section from an ivory osteoma of the skull. 




OSTEOMATA. 



635 



Fig. 127. 



are covered with twenty to fifty long, sharp, bony processes, where 
the tendons are attached to the bone (Fig. 
127) ; as in one case observed in Zurich, 
the ossification occasionally occurs in the 
fascia of the muscle. Cases have been ob- 
served where this ossification was so exten- 
sive that all the muscles of the shoulder 
and arm were ossified, and the upper ex- 
tremity could not be moved. These bony 
neoplasias, as well as the so-called exercise- 
bones, must doubtless be regarded as the 
product of chronic inflammation, just like 
the true bony formations that are abnor- 
mally developed in the membranes of the 
brain and spinal medulla. By exercise- 
bones we mean the development of bone 
in the deltoid muscle, particularly at those 
points where the musket strikes when drill- 
ing. But these bones form in few sol- 
diers, and their development presupposes 
a tendency to the formation of bone. Os- 
sification of the tendons, especially of their 
points of attachment to the bone, which 
occasionally occurs from some unknown 
cause, is also very remarkable, and reminds 
us of a similar process in birds, which in 
them is perfectly normal. 

The predisposition to formation of os- 
teomata is allied to that for development of 
chondromata ; it also occurs more frequent- 
ly in the young, and in men than in 
women, while children almost escape it. 
As regards epiphyseal osteomata, which might be termed ossifying 
chondromata, they of course cannot occur later than the twenty- 
fourth year. But other exostoses also occur generally before the thir- 
tieth year ; observations on this point are not very numerous, as the 
disease is rare. This experience about the occurrence of osteomata in 
the young is the more remarkable, as it stands in a certain contrast to 
the general rule of ossification being especially apt to occur in old 
persons. The cartilages of the ribs and larynx and the spinal liga- 
ments often ossify in advanced age ; the chalky deposits in the ar- 
teries of the aged also form part of the almost natural senile maras- 
mus ; development of osteomata, however, rarely occurs in old persons, 




Osteoma of the muscular attach- 
ments, after 0. Weber. 



636 TUMORS. 

but when such tumors are found in them they have usually developed 
in youth. Osteomata are just as often multiple as solitary; their 
growth is generally very slow, and is usually arrested with advancing 
age. The growth of epiphyseal exostoses ceases after the skeleton 
has completed its growth, and its spongy substance becomes more 
compact. Ossification of the tendons and muscles rarely goes so far 
as to entirely prevent motion. In some cases development of bone 
has been observed in the lung. The inconveniences caused by osteo- 
mata are not usually great ; their development is not accompanied by 
pain, nor are they sensitive to the touch ; but osteomata in the vicin- 
ity of joints often impair their function. When these tumors occur 
on the bones of the face, they cause unpleasant deformities ; exostoses 
on the big-toe prevent wearing the shoe ; ossification of the tendons 
and muscles impairs or entirely prevents motion ; but unfortunately, 
from their size and number, operative surgery can do little for the lat- 
ter, and the less so, as the tendency to morbid development of bone 
still continues. The operation for exostosis consists in sawing or 
chiselling the tumor from the bone affected. But, as the latter is 
occasionally in the vicinity of a joint, the articulation might thus be 
opened ; it is neither advisable nor necessary to undertake such opera- 
tions unless the impairment of function be so great as to balance an 
operation dangerous to the joint and to life. We should be the less 
inclined to undertake such operations without some special indication, 
as in the course of time these tumors cease to grow. On epiphyseal 
exostoses we occasionally find mucous bursas containing adherent, or 
loose ossifying chondromata ; these mucous bursas usually communi- 
cate with the joint in whose vicinity the exostosis is situated. Ac- 
cording to the investigations of Mindfleisch, the mucous bursas are 
always abnormal elongations of the pockets of the articular synovial 
membrane. I once allowed myself to be induced, by the entreaties 
of a patient, to remove such an exostosis on the lower end of the 
femur with a large mucous bursa; the patient died of septicaemia. 
In another case the mucous bursa over an exostosis on the lower end 
of the humerus opened spontaneously after moderate inflammation j 
there was suppuration of the elbow-joint, with anchylosis; the patient 
would not permit resection of the joint. 



MYOMATA, NEUROMATA. 637 

LECTURE XLVII. 

5. Myoma. — 6. Neuroma. — 7- Angioma: a, Plexiform ; 5, Cavernous.— Operations. 

5. MYOMATA. 

At present it remains undecided whether there are pure myomata y 
i. e., tumors consisting entirely of transversely-striated muscle-fila- 
ments or their cells ; I do not know that any such have been observed. 
The occurrence of newly-formed transversely-striated muscle-fila- 
ments has been very rarely observed in tumors. No tumor was ever 
entirely composed of them ; they were usual]y an accidental occur- 
rence in sarcoma or carcinoma (of the testicle, ovary, or mamma), or 
in tumors of very complicated formation. I have examined tumors in 
which there were distinct stages of development of muscular fila- 
ments, but the right of classing such tumors as myomata has been 
disputed. I can say little against this, as we cannot call tumors, con- 
sisting of grades of development of connective tissue, fibromata, and 
as I formerly objected (page 619) to terming uterus fibroma, composed 
of spindle-cells, myomata, as we are not quite sure of the relation of 
spindle-cells to muscle-cells. In old men, extensive newly-formed 
smooth muscles occur in the prostate, partly as independent nodules, 
partly as diffuse enlargements of the organ. There is certainly no 
objection to terming these so-called prostatic hypertrophies (there 
is usually some coincident glandular) myoma ; similar myoma-nodules, 
are met in the muscular coat of the oesophagus and stomach. Clinically, 
nothing certain can be said of myomata in these conditions ; the tu- 
mors which I considered as young myomata in the muscles had, on 
section, a medullary fascicular appearance an insuperable tendency to 
local recurrence, and thus caused death. 

6. NEUEOMATA. 

It has already been mentioned (page 622) that the name " neuro- 
ma " is often applied to tumors occurring on the nerves ; this is, if 
you please, a practical misuse, which, however, it is difficult to root out. 
By " true neuroma " we mean a tumor composed entirely of nerve- 
filaments, especially of those with double contours ; they appear to 
come only on nerves, and are very rare. Neuromata in amputation- 
stumps have already been mentioned (page 117) ; many doubt whethei 
there are any other true neuromata. True neuromata are always very 
painful. Many of the fibromata on and in nerves contain very peculiar 
bundle-like fine filaments richly supplied with nuclei, which may very 



638 TUMORS. 

well be taken for gray filaments containing no medulla, as Virchow 
considers them ; this would make true neuromata a large class, and di- 
vide them into myaline and amyaline forms. I do not always trust 
myself to distinguish an amyline neuroma from a fibroma in a nerve, 
and hence should not require it of others. Tumors composed of spin- 
dle-cells arranged in bundles are probably far oftener young myomata 
and neuromata than young fibromata, but it would be difficult to prove 
to which class they belong. Multiplicity and tendency to regional 
recurrence are peculiar to neuromata, hence the prognosis should 
always be guarded. It is rarely possible to dissect a neuroma from 
the nerve ; part of the latter must generally be removed with it. 

7. ANGIOMATA— VASCULAE TUMOES. 

By this term we mean tumors composed almost exclusively of ves- 
sels held together by a slight amount of connective tissue ; they have 
also been called [nasvi, mother's-marks] " erectile tumors," being firm- 
er or softer, larger or smaller, according to the fulness of the vessels. 
The ordinary forms of varicose dilatations of the veins and the aneu- 
risms of different arteries are excluded by this definition. But circoid 
aneurism and some forms of aneurismal varix might be classed here ; 
yet, as this is not customary, we treated of these diseases earlier. 
Here we have to consider two different varieties of vascular tumors : 

(a.) The plexiform angioma or telangiectasis (from reXog, ayyeiov, 
Enraotg), This is the most frequent form ; this neoplasia is composed 
entirely of dilated and tortuous capillaries, and anastomosing vessels, 
and, according as the proliferation of the vessels or the pure ectasia 
predominates, it appears more as a tumor or as a red spot on the 
skin. Plexiform angiomata, of the variety we are about to describe, 
occur almost exclusively in the cutis. They have sometimes a dark- 
cherry, at others a steel-blue color ; are sometimes as large as a pin- 
head, again as large as a hemp-seed ; some are moderately thick, 
others scarcely rise above the level of the skin. There are very rare 
forms w T here there is not a red spot or a tumor, but a diffuse redness 
over a large surface ; in such cases, even with the naked eye, we usu- 
ally see the distended and looped fine vessels on the surface of the 
cutis, showing through the epidermis. Anatomical examination of 
large extirpated angiomata of this variety shows that they are com- 
posed of small lobuli as large as a hemp-seed or a pea ; and, if, after 
artificial injection or other mode of preparation, we examine them 
microscopically, we shall find that these lobuli are formed by the ves- 
sels of the sweat-glands, hair-follicles, fat-glands, and fat-lobuli, being 
independently diseased, and that the different small proliferating, vas- 
cular systems form the above-mentioned lobuli, which are visible to 



AXGIOMATA. 



039 



the naked eye. The reason for the color of these tumors being some- 
times blood-red, sometimes pale bluish, is that, in the former case, the 
capillaries of the most superficial layer of cutis, in the second, the 
deeper vessels, are diseased. As a rule, this proliferation of vessels 
does not go beyond the subcutaneous cellular tissue ; rarely it affects 
the deeper tissues, such as the muscles ; whence it appears that these 
neoplasias not only grow centrally, but especially peripherally, and 
destroy the part affected. Most of these tumors may be slowly emp- 

Fig. 128. 




Con florae ration of vessels from a plexiform angioma. Magnified 60 diameters, a, proliferating 
vascular net-work around a sweat-gland ("which is not shown, to prevent complicating the 
drawing) ; 6, proliferating vascular net-work in the papillae of the oral mucous membrane. 

tied by pressure, and again fill as soon as the pressure ceases. But 
there are also moderate-sized telangiectases, in which, besides the 
proliferation of vessels, there is also a new formation of connective 
tissue and fat, so that they cannot be entirely removed by pressure. 
When these new formations were superficial in the cutis, and the 
blood has been emptied from them after extirpation, with the naked 
eye we can hardly see any thing abnormal in the morbid piece of skin 
that has been removed ; a moderate neoplasia of this variety appears 
on the cut surface as a pale-reddish, soft, lobulated substance, in which 
we can see no vessels with the naked eye, because the whole disease 
is usually limited to the capillaries and minute vessels, and to a few 
small arteries. 



640 



TUMORS. 



(b.) Cavernous angiomata, or cavernous venous tumors. We wih 
first determine their anatomy, so that you may at once correctly note 
their difference from plexiform angiomata. Extirpated cavernous 
angiomata may at once be recognized, on section, by having almost 
exactly the formation of the corpus cavernosum penis. You see a 
white, firm, tough net-work, which appears empty, or at least con- 
tains only in spots red or discolored coagula, or possibly is filled with 
small, round, chalky concrements, so-called vein-stones ; but we must 
imagine the mesh-work as distended with blood previous to its extir- 
pation. The boundary of this cavernous tissue, which may form in all 
the tissues of the body, is sometimes evidently a sort of capsule ; but 
in other cases this cavernous degeneration is very indistinctly bounded, 
and at different spots, in a rather indifferent manner, it enters the 
tissue. Microscopic examination of this mesh-work, which is formed 
sometimes of thin threads, sometimes of membrane-like capsules, 
shows that the branches are formed of remains of the tissue in which 



Fio. 129. 




Mesh-work from a cavernous angioma of tne lip (the blood is to be imagined in the large meshes 
between the net-work). Magnified 350 diameters. 



the cavernous ectasia occurs. The inner wall of the space filled with 
blood is, in most cases, coated with spindle-shaped cells (venous endo- 
thelium), so that even these anatomical conditioDS go to prove that we 
have to deal chiefly with distended veins. The mode of development 
of this peculiar tissue has received different explanations. 

If we had any accurate investigations about the development of 



ANGIOMATA. 641 

the corpus cavernosum penis, we might draw some definite conclusions 
from them, on account of the great analogy of the two tissues. The 
three chief hypotheses about the development of cavernous tumors 
are as follows : 1. It is asserted that the cavernous spaces first develop 
from the connective-tissue, and secondarily become connected with 
the vessels ; and it has even been suggested that blood might be de- 
veloped outside of the circulation, from the derivatives of the connec- 
tive-tissue cells ; the striae of the mesh-work would increase by inde- 
pendent growth, by sprouting, and club-shaped growth of the connec- 
tive tissue (Roltitansky). This hypothesis, especially the formation 
of blood outside of the circulation, has some objections. 2. It is 
asserted that circumscribed dilatations of small veins occur close to- 
gether, and that at the points where they come in contact the walls 
are gradually thinned or entirely disappear. This view is supported 
by the fact that these gradual distentions of the veins may occasion- 
ally be distinctly followed out both in the cutis and bones when these 
tumors are developing. 3. JRmdfleisch claims that vascular ectasia, 
especially in the cavernous tumors which form in the orbital fat, is 
always preceded by infiltration of the tissues with small cells, which 
is followed by a sort of cicatricial shrinking of the tissue, and conse- 
quent tearing apart of the vessels, whose calibre must constantly be 
increased by continued atrophy of the intermediate tissue. 

For some reasons I have long supposed that both in plexiform and 
cavernous angiomata there was some process similar to inflammation, 
but neither the latter (scarcely applicable to the cavernous tumors in 
bones) nor the former two hypotheses appear to fully explain the 
causes and peculiar differences in the distention of the vessels. We 
have still to mention one difference between cavernous tumors : they 
are either connected with the large venous trunks, as sacs to the sub- 
cutaneous veins, or numerous small arteries and veins sink into the 
capsule of the cavernous tissue. Lastly we must mention that these 
cavernous venous ectasias may occur accidentally in other tumors as in 
fibroma and lipoma, as has already been mentioned. A few years 
since I extirpated a lobular lipoma, which had formed below the 
scapula of a vigorous young man, all of the lobes of which had 
centrally degenerated to cavernous tissue. Cavernous angiomata de- 
velop with especial frequency in the subcutaneous cellular tissue, 
more rarely in the cutis and muscles, very rarely in bones, but quite 
often in the liver, particularly on its surface, occasionally also in the 
spleen and kidneys. They are sometimes quite painful, other cases 
are not at all so. 

The diagnosis of cavernous angiomata is not always easy ; when 
they occur in the cutis, they may be mistaken for more deeply-seated 
41 



642 TUMORS. 

telangiectases, although the blood may be pressed out of the cavernous 
venous tumors more readily than from telangiectases. Deeply-seated 
tumors of this sort are always difficult to recognize with certainty ; 
the}' usually show decided fluctuation, are somewhat compressible, 
swell on forced expiration ; but the last two symptoms are not always 
distinct, hence they may readily be mistaken for lipomata, cysts, and 
other soft tumors ; sometimes, indeed, this mistake cannot be avoided. 

Probably half the angiomata are congenital, or at least developed 
soon after birth. If they develop during life, it is usually in childhood 
or youth ; it is rare for vascular tumors to occur during manhood or 
old age, which is very remarkable, as the disposition to vascular dis- 
eases, especially to ectasia of the vessels, greatly increases with ad- 
vanced age. Not only the larger arteries and veins dilate at this 
time, but also the small anastomosing vessels and capillaries, at certain 
localities, show visible dilatations through the skin. On the face of 
a ruddy, healthy old man we see red cheeks as we do in the young; 
it is not, however, the regular rosy bloom of a maiden's cheek, but 
a more bluish red, and, if you look more closely, you find numerous 
tortuous vessels, visible to the naked eye ; in some, this redness occurs 
in spots. These small vascular ectasias do not occur in all old persons, 
so that we must suppose them due to a peculiar predisposition. Hence, 
as we said, in spite of the fact that advanced age is more disposed to 
disease of the vessels than any other time of life, true vascular tumors 
develop almost exclusively in youth. There is no doubt that the te- 
langiectasias, which popularly are often called " mother's-marks," are 
often inherited. This appears to be proved by a number of stories 
about children, that have been lost, being subsequently recognized by 
marks inherited from the father or mother. We should undoubtedly 
learn far more of the hereditary transmission of vascular tumors if we 
would attend more to that of diseases of the vessels generally. Even 
if plexiform and cavernous angiomata are to be regarded as anatomi- 
cally distinct from each other, and from the different varieties of va- 
rices and aneurisms, it is still clear that a predisposition to dilatation 
of the vessels is at the root of all of them ; this is undoubtedly to a 
great extent inherited, and the above diseases can only be regarded 
as different modes of appearance of this predisposition at different 
ages. Hitherto attention has been so exclusively paid to the ana- 
tomical conditions of the tumors that the classes of diseases accom- 
panying them have been too little noted. 

As regards the further fate of angioma, telangiectasia?, which are 
almost always congenital, may be either solitary or multiple. Their 
growth is alwaj^s slow, painless, and is sometimes chiefly superficial 
again in the depth, and usually at the expense of the diseased tissue. 



AXGIOHATA. 643 

There is no doubt that occasionally in the course of years these tumors 
cease to grow, but remain unchanged. But in other cases the growth 
continues so that the tumors, as I once saw on the neck of a boy five 
years old, may grow almost as large as a man's fist. Frequently two 
or three telangiectases occur congenitally, or occur in quick succes- 
sion, especially on the scalp, more rarely there are six or eight, I 
have seen two cases of flat congenital plexiform angiomata of the left 
side of the face, which healed at some points, partly from ulceration, 
partly from unknown causes; i. e.. cicatricial white spots occurred here 
and there, where the vessels were obliterated, while in the periphery 
the proliferation progressed. 

Cavernous angiomata are rarely congenital, but generally occur in 
childhood or youth, more rarely later in life. As already remarked, 
their seat is chiefly in the subcutaneous cellular tissue, more frequent- 
ly in the face, more rarely on the trunk and extremities. They 
often occur in large numbers, but in such a way that a certain vas- 
cular district is to be regarded as the seat of disease, as an arm, a 
foot, leg, or face, etc. Besides the disfigurement, the symptoms in- 
duced are a certain weakness of the muscles, and occasionally pain in 
the part affected. The tumors may attain considerable size, and thus 
especially on the head prove dangerous, the more so, as by further 
progress they enter and destroy the bone. Some observations that I 
know of show that in these tumors, as a result of thrombosis of the 
cavernous spaces, there may be atrophy and retrogression (especially 
in the cavernous tumors of the liver) ; but complete disappearance of 
the angioma by spontaneous obliteration has not been observed. — 
Treatment for vascular tumors is very varied. The operations have 
two different objects : 

1. Methods aiming at coagulation of the blood, with consequent 
obliteration and atrophy of the tumor. Among these are injecting 
the tumor with liquor ferri sesquichlorati ; also transfixing them 
with hot needles, or the galvano-cautery, and drawing a platinum wire 
through, and subsequently heating it with the galvano-caustic appa- 
ratus (galvano-caustic setaceum). We must also mention continued 
compression of the tumor and ligation of the afferent artery. Both of 
the latter have gone out of use, as they have proved entirely worthless. 

2. Methods aiming at the removal of the angioma : 

(a.) By ligation ; in telangiectasis with a broad base this must 
be double or multiple. A needle with a double ligature is passed 
through under the tumor ; one ligature is tied to one side, the other 
to the other side of the base of the tumor. 

(b.) In vaccinating on the tumor, so that, when the vaccine scab 
falls, the tumor may be removed. 



644 TUMORS. 

(c. ) Cauterization ; for this purpose fuming- nitric acid is best ; it 
should be applied by a rod about as thick as a goose-quill, till the 
angioma assumes a yellowish-green color. 

(cL) By extirpation with the scissors or knife. 

After some experience in operating, the choice of these methods 
in any given case is not difficult. In superficial angiomata, if not al- 
together too extensive, and not so situated, that the subsequent cica- 
tricial contraction would cause decided deformity, as on some parts 
of the face, I regard cauterization with fuming nitric acid as the proper 
method. In extensive plexiform, and in the cavernous angiomata, re- 
moval with the knife and scissors is the most certain operation. Too 
profuse haemorrhages in such operations may be prevented partly by 
compression of the parts around by skilled assistants, and the rapid 
application of the suture, partly by free mediate ligation of the whole 
periphery of the tumor. In many eases of angioma of the face also 
extirpation is to be preferred to cauterization, because the incision 
may be so directed that the subsequent cicatricial contraction shall 
induce no distortion of the eyelids or angle of the mouth. But there 
are cases where extirpation is entirely impracticable, partly from the 
size, partly from the seat or number of such tumors. I treated a 
child, with a still growing cavernous tumor which extended from the 
glabella, through the nose and whole upper lip. If it had been de- 
sired to extirpate this, it would have been necessary to remove the 
whole nose and upper lip ; of course, this was not to be thought of ; 
hence I tried cauterization with heated needles. The treatment had 
lasted three months, and would have taken as much longer, although 
a large part of the cavernous space was already obliterated, when the 
mother of the child unfortunately lost patience, and I never saw it 
again. I prefer this mode of cauterization to the injection of liquor 
ferri, as suppuration and gangrene occasionally follow the latter, and 
as the injection is occasionally rendered difficult by the fine canula 
being stopped by coagula. The other methods are of very secondary 
importance ; vaccination frequently does not go deep enough, and the 
ligature is a tedious, uncertain method, which is sometimes rendered 
dangerous by secondary Tioemorrhage- 



In the form of an appendix I may also mention : 

1. Cavernous lymphatic tumors (lymphangioma cavernosum), a 
very rare form of neoplasm, which is of the same anatomical for- 
mation as cavernous blood-tumors, but with the difference that, in- 
stead of blood, there is lymph in the mesh- work. This variety of 
the tumor occurs congenitally in the tongue as a form of macro^los- 






SARCOMATA. 645 

Bia (there is also a fibrous form) ; in young persons it sometimes oc- 
curs at different parts of the subcutaneous cellular tissue (lips, cheeks, 
chin, thigh). 

2. JVcevus vasculosus, the so-called fire-mole ; this is a plexiform 
angioma of the most superficial cutaneous vessels, which ceases to 
grow from the moment of birth. There is no other difference be- 
tween fire-mole and growing angioma. I have already said that there 
are various combinations of hypertrophy of the skin, pigmentation, 
ectasia of the vessels, and formation of hair in these congenital marks. 
If these marks be on the face, and not too large (sometimes they im- 
plicate half the face), we may extirpate them partly or entirely, and 
subsequently make a plastic operation, or we may resort to cauteriza- 
tion. Some of these marks, where only the tops of the papillae are 
affected, may be greatly improved or even cured by a very superficial 
peeling of the skin. 

LECTURE XLVIII. 

8. Sarcomata. — Anatomy : a, Granulation Sarcoma ; 5, Spindle-celled Sarcoma ; <;, Giant- 
celled Sarcoma ; d, Stellate Sarcoma ; e, Alveolar Sarcoma ; /, Pigmented Sarcoma. 
— Clinical Appearance. — Diagnosis. — Course. — Prognosis. — Mode of Infection. — 
Topography. — Central Osteosarcoma. — Periosteal Sarcoma. — Sarcoma of the Mam- 
ma, of the Salivary Glands. — 9. Lymphomata. — Anatomy. — Eelations to Leucasniia, 
— Treatment. 

8. SAECOMATA. 

Over no group of tumors has there so long been uncertainty 
about their anatomical position and extent as about sarcoma. The 
old name, taken from crap%, flesh, merely meant that on section the 
tumor had a fleshy look ; of course, this did not make a diagnosis, 
as it was greatly a matter of choice what should be called flesh. 
The attempt to employ the name "sarcoma" solely for tumors com- 
posed of muscle filaments (Schuh), that is, to identify it with those 
tumors now called " myoma," was not popular. Subsequently the 
term became somewhat more definite, as it was made to include all 
tumors rich in cells which had no decided alveolar formation, and were 
not carcinomatous. It is only for the last ten years that the follow- 
ing histological definition has received general acceptance and has 
become quite common. A sarcoma is a tumor consisting of tissue be- 
longing to the developmental series of connective-tissue substances 
(connective tissue, cartilage, bone), muscles, and nerves, which, as a 
rule, does not go on to the formation of a perfect tissue, but to pecu- 
liar degenerations of the developmental forms. Some pathologists 
would gladly see "muscles and nerves" excluded from this definition, 
but when speaking of spindle-celled sarcoma I shall show why I can- 



646 



TUMORS. 



not admit this. If it is desired to term the inflammatory neoplasias m 
their various stages examples of sarcoma (Rindfleisch) , I assent tc 
it, as this definition would agree pretty well with mine. 

After this anatomical basis was found for " sarcoma," it soon ap- 
peared that it could be diagnosed, even with the naked eye, and that 
clinically also something could be said about the peculiar course of 
these tumors. As I think that the subdivisions, according to histo- 
logical peculiarities, are less important for the diagnosis of these tu- 
mors during life, and that their diagnosis, prognosis, and course, de- 
pend so much on their point of origin, the rapidity of their growth, 
etc., I prefer hereafter classing together the clinical remarks on sar- 
coma, and here merely considering more attentively the histology. 
We shall divide sarcoma into the following forms : 

Fig. 130, (a.) Granulation sarcoma^ round-celled sar- 

coma of Virchoio. This tissue is the same, or 
very like that of the upper layer of granulations ; 
it always contains chiefly small round cells, like 
lymph-cells ; the intercellular substance is some- 
times scarcely perceptible, again it is in greater 
quantities, and may be perfectly homogeneous, as 
in neuroglia ( Yirchow's glioma and giio-sarcoma), 
or it is slightly striated (Fig. 130), or even fibrous, 
or may be cedematous (as in large mammary sar- 
comata). Lastly, it may also be reticulate, and so approximate the tis- 
sue of lipoma. 

Fig. 131. 




Tissue of a granulation 
sarcoma. Magnified 350 
diameters. 




Tissue of a trlio-sarcoma, after Yvrclxow. Magnified 350 diameters. 

ib.) Spindle-celled sarcoma is composed of closely-packed, usually 
thin, elongated spindle-cells, so-called filament-cells. Usually there 






SARCOMATA. 



647 



Fig. 132. 



sCV Smii 




is no intercellular substance, occasionally there is some ; it may be 
homogeneous and soft, or fibrous ; if the fibrous portion preponderates, 
the tumor is called fibro-sarcoma, 
or fibroma. Formerly this spindle- 
celled tissue was termed young 
connective tissue (tissue fibroplas- 
tique, JOebert) ; but from my histo- 
genetic investigations in the em- 
bryo I have long protested against 
this view, for spindle-celled tissue, 
as we usually find it in these sar- 
comata, does not occur in embryonal 
tissue at any period, not even in the 
tendons ; the physiological exam- 
ple of this tissue is young muscle 
and nerve tissue; these spindle- 
celled sarcomata would then be 
young myomata or neuromata. 
Virchow has carried the same 
view further, especially as far as 
regards fibrous uterine tumors (page 
619). I protested against this 
view of Vir chow's, with its con- 
sequences, as the diagnosis is always doubtful in special cases. 
When a nerve contains a tumor consisting of elongated spindle- 
cells, whose ends terminate in fine filaments, it is very natural to re- 
gard it as a neuroma whose elements are not fully developed at any 
point. When a spindle-celled tumor is developed in muscle, and the 
fibre-cells show band-like forms, even fine granulation, as in the com- 
mencement of striation, there could be no blame for calling these tu- 
mors " myomata," under the idea that they were young muscle-tissue 
that had not gone beyond certain bounds of development. So far 
there is no objection to this view. But when a spindle-celled sarcoma 
comes in the cutis, or on the penis (where I recently saw a remark- 
able case), we may be very doubtful whether the case is one of young 
neuroma, myoma, or fibroma ; in both of these parts there are nerves, 
muscles, and connective tissue. If, then, there be nothing typical in 
the arrangement or form of the cells, and the histological mode of 
origin cannot be certainly determined, we must content ourselves with 
the term " spindle-celled sarcoma." At all events, we have to deal 
with a fibrous tissue, whose development has not advanced beyond 
the production of spindle-cells. Moreover, I think I can affirm from 
my observations that the course and prognosis of these tumors scarcely 



Tissue of a spindle-celled sarcoma. 



648 



TUMORS. 



Fig. 133. 



depend on their origin, but far more on their locality, rapidity of 
growth, consistence, and other clinical conditions. 

(c.) Giant-celled sarcoma is a 
name given by Virchow to a variety 
of sarcoma containing very large 
cells, which are partly round, partly 
polymorphous, and supplied with 
many offshoots (Fig. 133). These 
cells, which normally occur in the 
medulla of the bones of the foetus, 
although not so large as in tumors, 
have excited great astonishment by 
their size ; they are the largest un- 
formed protoplasm collections that 
have been seen in man ; they may 
contain thirty or more nuclei, and 
their origin from a simple cell by a series of transformations is gen- 
erally easily followed. These giant-cells occur in spindle-celled, as 
well as in fibro-sarcoma ; they occur somewhat smaller sporadically, 
and are also found in granulation and myxosarcomata. They are most 

Fig. 134. 




Giant-cells from a sarcoma of the lower 
jaw. Magnified 350 diameters. 




(Jiant-celled sarcoma with cysts and ossifying foci from the lower jaw. Magnified 350 

diameters. 



frequent in the central, less so in periosteal sarcoma, but I have seen 
them even in muscle-sarcoma. By their size they occasionally give 



SARCOMATA. 



649 



Fig. 135. 



the tissue an apparently alveolar (Fig. 134) structure, and by soften- 
ing may lead to formation of cysts («), or may ossify (£). 

A peculiar formation from sarcoma, which is allied to the giant- 
cell, although never growing very large, may be mentioned here, In 
a granulation-sarcoma of the dura mater, which ac- 
cidentally fell into my hands, there were great num- 
bers of globular, multinucleated cells, which were 
surrounded with a membrane-like connected layer of 
spindle-cells (Fig. 135). I hazard no explanation of 
these elements, but suspect that they are associated 
with the formation of tufts on the cerebral mem- 
branes, and with tufted fibro-sarcomata, which ~Vir* 
choic calls brain-sand tumors (psammone), when they 
contain brain-sand. Possibly, these peculiar forma- 
tions are aborted excrescences from blood-vessels, an 
idea I have long cherished, and which is apparently 
confirmed by a recently-published observation of 
Arndtywho saw these spheres attached to vessels by 
pedicles. Wcddeyer lately showed that these and 
allied formations, which occur especially in intracranial tumors) start 
from the perithelial (adventitial) cells of cerebral vessels. The neo- 
plasias belonging here, but not yet sufficiently analyzed and classified, 




Cell-globules from a 
sarcoma of the dura 
mater. Magnified 
350 diameters. 



Fig. 136. 



Fig. 131 





Mucous tissue from a myxosarcoma of the 
scalp. Magnified 400. 



Mucous tissue from an adenomyxoma 
of the mamma. Magnified 400. 



650 TUMORS. 

as well as the alveolar sarcomata of which we shall soon treat, often 
so much resemble carcinomata in their structure that they are very 
difficult to distinguish. According to recent observations, especially 
those of Sattler, what I formerly described as cylindroma, and erro- 
neously classed with adenoma, also belongs in this class. 

(d.) Net-celled sarcoma. Mucous sarcoma. (Gelatinous sarcoma 
of Mokitanshy.) For the offshoots from cells to develop well and be 
distinctly seen, there must be considerable soft intercellular substance 
present. Hence sarcomata with gelatinous mucous intercellular sub- 
stance, which contain any stellate cells, are the most beautiful. But 
this is not always the case. There are also granulation-sarcomataj 
that have a claim to be regarded as mucous or gelatinous tumors. 
If we should wish to class the tumors from the above groups, when 
they appear gelatinous, together because they contain much mucous 
{jiv^a)^ we may call them myxomata (Virchow), or retain their old 
name, collonema (X Jfuller). VirchouPs true mucous tissue (Fig. 
135) undoubtedly belongs to the developmental series of the connec- 
tive tissues ; occasionally it also occurs in mucous granulations. But 
frequently also we find spindle-cells and round cells in myxoma, and, 
if there be at the same time any developed cartilage, the mucous tis- 
sue may be regarded as young or softened cartilage-tissue, which be- 
comes the more probable if a myoxoma contains honey-comb-like 
septa such as are found in chondroma. "We may use the terms 
myxosarcoma, myxochondroma, etc. 

(e.) Alveolar sarcoma. This rare form of tumor (occurring in the 
cutis, muscle, and bone) is very difficult to characterize anatomically ; 
from the size and arrangement of its cells, it may in spots so much 
resemble carcinoma, that I would not trust myself to decide correctly 
on every piece of such a tumor placed under the microscope. The 
cells of these elements are much larger than lymph-cells, about the 
size of cartilage-cells, or of moderately large flat epithelium, and 
usually have one or more large nuclei, with glistening nucleoli. The 
cells are embedded in a fibrous, or more rarely homogeneous, slightly- 
developed intercellular substance of exquisite alveolar type, in such a 
way that they lie together separately, or more rarely in groups (Figs. 
138 and 139). They are most intimately connected with the fibres, 
and are difficult to detach from the fibrous mass. The latter two pe- 
culiarities are important for the histological diagnosis of " sarcoma," 
for they show the large cells are connective-tissue cells, not epithelial 
cells, as in true carcinoma-tissue. Occasionally the cellular elements 
of these sarcomata lie in immediate contact, without any intercellular 
substance; the resemblance to epithelial carcinoma may prove de- 
ceptive. Virchow has described and deduced this form from soft 
warts of the cutis. 



SARCOMATA. 



651 



Pig. 138 




Alveolar sarcoma from the deltoid muscle. 
Mamifled 400 diameters. 



Alveolar sarcoma from the tibia. 
Magnified 4)0 diameters. 



(f.) Pigmentary sarcoma. Melanotic sarcoma. 3felanoma. AH 
these names indicate pigment formation in sarcoma. This pigment, 
which is usually granular, rarely diffuse, is brown or black, lies almost 
always in the cells, rarely in the intercellular substance. Part or the 
whole of the tumor may be faintly or distinctly black. Any of the 
above forms of sarcoma may occasionally be pigmented, but I have 
most frequently found this to be the case in the last form, and in the 
spindle-celled sarcoma. Melanomata develop most frequently in the 
cutis, especially of the foot and hand, but also on the head, neck, and 
trunk. 

The arrangement of the cellular elements in sarcoma depends, on 
the one hand, on certain directions of the fibres or fibre-cells in the 
tissue of the tumor ; on the other, on the form of the vascular net- 
work ; from these circumstances, as well as from the development of 
giant-cells, or similar formations, there may result an arrangement of 
the tissue of the tumor, scarcely distinguishable from the areolar 
formation formerly ascribed exclusively to carcinoma-tissue. This 
should not astonish you, for in cartilage also we have a type of cavi- 
ties with enclosed cells, and also the net-work of the lymphatic glands, 
which undoubtedly belong to the system of connective-tissue sub- 
stances, but must also be termed alveolar formations. 33 



652 TUMORS. 

Coming now to the symptoms of sarcoma perceptible to the naked 
eye, we must first state that in most cases these neoplasias have a 
roundish, sharply-bounded form, indeed, are usually distinctly encap- 
sulated ; this is a very important distinguishing mark from infiltrated 
carcinoma. Sarcoma very rarely appears on surfaces (whether free or 
sac-like membranes) in a papillary or polypous form ; still, there are 
non-glandular nasal and uterine polypi, also soft warts on the skin 
and mucous membrane, which, from their histological structure, can 
only be classed among the sarcomata. The consistence and color of 
sarcomata vary so much that nothing general can be said about 
them ; they may be as hard as cartilage, or of gelatinous, nearly fluid 
consistence. On incision, the tumor may appear bright red, white, 
yellowish, brown, gray, black, dark red, and different shades of all 
these colors may appear on the same cut surface, apart from the pig- 
mentation ; this depends especially on their vascularity, and on more 
or less recent extravasations of blood in the tumor. The vascularity 
varies greatly ; sometimes there is only a scanty net-work of vessels ; 
again, the tumor is like a sponge, traversed by cavernous veins. "We 
must here mention another peculiarity of sarcoma : it is occasionally 
so white that, if it be soft at the same time, it greatly resembles 
brain-matter. This medullary sarcoma (encephaloid) usually has all 
the malignant qualities of sarcoma in the highest grade, and is much 
feared ; it may have any of the above-described histological charac- 
ters. Tumors which may be torn up into bundles in certain directions 
have been called sarcoma fasciculatum (formerly carcinoma fascicu- 
latum). The anatomical metamorphoses that take place in sarcoma 
are various : the different modes of softening predominate ; mucous 
softening, even to the formation of mucous cysts, fatty and cheesy 
degenerations, are frequent. Ossification is very common in sarco- 
mata connected with bone, and may go on until the w r hole tumor is 
more or less completely transformed to bone. Cicatricial shrinkage 
scarcely ever occurs in sarcoma ; this is another important difference 
from carcinoma. Ulceration from within outward, opening out like a 
crater, is rare ; sarcomata of the cutis ulcerate early, without, however, 
causing extensive destruction ; ulceration of hard sarcomata occasion- 
ally produces well-developed granulations. 

The diagnosis of sarcoma during life is made by attending to the 
following points: Sarcomata develop with peculiar frequency after 
precedent local irritations, especially after injuries ; cicatrices, also, 
are not unfrequently the seat of these tumors ; black sarcomata may 
come from irritated moles. Skin, muscles, nerves, bone, periosteum, 
and, more rarely, glands (among these the mamma most frequently), 
are the seats of these tumors. Sarcomata are rarest in children, rare 



SARCOMATA. 653 

between ten and twenty years, most frequent in middle life, and rarer 
again in old age. According to my observation, men and women are 
affected with equal frequency. If these tumors be not located in 
or on nerve-trunks, they are usually painless till they break out. If 
the sarcoma be in the subcutaneous cellular tissue or in the breast, it 
may be felt as an encapsulated movable tumor. The growth is some- 
times rapid, sometimes slow ; the consistence varies, so that it can 
scarcely be used as a point in diagnosis. 

Course and progiiosis. A sarcoma may develop solitarily, may 
remain so, and never return after operation. It may develop as soli- 
tary or multiple, and return after repeated extirpation ; metastatic 
tumors may form in the lungs or liver, and thus this disease may cause 
death in three months. You see that the greatest benignity and 
greatest malignity may be united in this one group of neoplasia ; in- 
deed, I can assure you that two sarcomata of the most similar histo- 
logical qualities (usually, however, with different consistence) may 
differ entirely in course. From this circumstance the greatest objec- 
tions have been made to pathological histology ; it must be acknowl- 
edged that the histological structure of a tumor by no means corre- 
sponds to its clinical course ; but for this reason to cast a slur on 
anatomy would be just as strange as to blame it because we cannot 
certainly distinguish between the microscopic preparations of a sali- 
vary, lachrymal, or mucous gland, although they play very different 
parts in the organism. We must first overcome the habit of seeking 
specific anatomical forms for specific functions. But there is no lack 
of indications for prognosis in regard to any sarcoma. We shall 
hereafter speak of the importance in this respect of the location of 
the tumor ; the consistence is important, firm sarcomata are of better 
prognosis than soft ones ; alveolar forms are of especially bad prognosis, 
and still more so are the soft granulation and spindle-celled sarcomata, 
which usually appear in the medullary form ; black sarcomata are also 
especially dangerous, the firm ones being less rapid in their course than 
the soft. The rapidity of the growth first appearing is very impor- 
tant for the prognosis ; this is, moreover, in proportion to the consist- 
ence ; if a sarcoma has taken four or five years to attain the size of a 
hen's egg, the prognosis is not so bad ; if in four or five weeks it has 
grown to the size of a fist, it is very bad. A sarcoma may be mis- 
taken for a cold abscess ; I know of one case where a sarcoma of the 
abdominal walls developed so rapidly that at first it was diagnosed to 
be furuncle. In a few months the patient was covered with sarco- 
mata, and, in less than three months from the development of the first 
tumor, she died from the disease attacking the lungs. Sometimes, 
however, a slowly-growinf firm sarcoma is followed by one of rapid 



654 TUMORS. 

growth, but the reverse of this never occurs. Usually, sarcomata 
develop in strong, well-nourished, often in particularly healthy and fat- 
persons ; I saw a medullary sarcoma of the mamma in a blooming, 
strong, healthy girl eighteen years old ; she died of sarcoma of the 
lungs a few months after operation. The mode of development of 
sarcomata which appear successively is very characteristic. The first 
tumor is completely extirpated ; after a time, in, under, or near the 
cicatrix, a new tumor appears ; this also is completely removed ; again, 
a new tumor appears at the point of operation, or at a slight distance 
from it, and near it other new ones ; the patient begins to emaciate ; 
possibly further operations are not practicable, marasmus occurs, pos- 
sibly lung or liver tumors, with their symptoms, develop ; the patient 
dies from suppuration from the primary tumor, or from disease of in- 
ternal organs. The course just described differs from that of carci- 
noma, because in the latter continuous recurrence is the most frequent, 
while in sarcoma the regional predominates, provided the tumor has 
been entirely extirpated. This may readily be explained by the fact 
that the bounds of infiltrated carcinoma are much more difficult to 
determine than are those of encapsulated sarcoma : hence, ceteris pari- 
bus^ the latter may be more certainly removed ; if portions of sar- 
coma be left, of course there will be continuous recurrence. After 
complete extirpation of sarcoma, years may elapse before the regional 
recurrence, and sarcoma may always remain a local trouble for years, 
possibly till death. I know one case of fibro-sarcoma of the back of the 
head, where it was twenty-three years from the development of the first 
tumor till death from recurring tumors ; meantime, the patient was 
operated on five times, and, on each occasion, he was cured for some 
time. From an old woman I extirpated a medullary sarcoma (alveolar 
cancerous form, Fig. 138) from the deltoid muscle ; the wound had 
scarcely healed when a new sarcoma, like the first, formed in it ; now 
the woman remained perfectly well four years, then a new tumor came 
in the deltoid ; it was removed by an operation, probably imperfect, 
and recurred in the incomplete cicatrix ; exarticulation of the arm was 
followed by recurrence in the pectoral and latissimus muscles, and 
death from sarcoma of the lungs and pleurisy. A year since, I extir- 
pated a melanotic, large-celled sarcoma from the scalp of an old man, 
from whom Schuh had, six years previously, removed a similar tumor; 
up to the present time there has been no recurrence. When we am- 
putate the thigh for sarcoma of the leg, after years it may recur in the 
amputation-cicatrix, and be followed by sarcoma of the lungs. The 
local tendency to recur could be explained by an extensive sprinkling 
of seed in the vicinity of a tumor, if the recurrences succeeded each 
other rapidly, but, when years elapse between the recurrences, this ex- 



SARCOMATA. 



655 



planation will hardly answer, for it is not very probable that tumor 
cells would lie quiet in the tissue for years, and then suddenly shoot 
out like an old seed. I know no explanation for this mode of recur- 
rence. The course of the infection is very peculiar in sarcoma ; I think 
I was one of the first to show that it is an essential peculiarity of sar- 
coma, that it does not attack the lymphatic glands, or does so quite 
late in the disease. The course of sarcoma-infection goes chiefly, if 
not exclusively, through the veins — not, as in carcinoma, through the 
lymphatic vessels. Sarcomata of the lungs are mostly of embolic 
origin ; it seems that the walls of the veins in sarcoma are very readily 
traversed by the tumor-substance, and their calibre filled with friable 
masses of it, which thence pass into the lungs. The number of the 
secondary sarcomata is often enormous, the whole pleura and peri- 
tonaeum may be covered with them. In this respect, the melanotic 
forms almost appear to dispute the precedence with the medullary. 
Primary, only partially-pigmented tumors are occasionally followed 



Fig. 140. 



Fig. 141. 





Central osteosarcoma of the ulna, from the collection 
of the surgical clinic of the University at Berlin. 



Section of Fig. 1 10. 



by perfectly black and also by perfectly white seconda^ tumors. Sar- 
comata of the lungs are almost always of the granulation variety. Id 



656 



TUMORS. 



the liver I have seen secondary, very beautifully pigmented, spindle- 
celled sarcomata ; the forms of primary and. secondary sarcomata thus 
vary greatly. 

Topography of sarcoma. As the above general remarks are in- 
sufficient for practice, we must study more accurately different fores 
of sarcoma in certain tissues and in certain parts of the body. 

Sarcomata occur quite often in hollow bones (myeloid tumors or 
central osteosarcoma), usually in the form of giant-celled sarcoma ; 
they especially attack the lower jaw, next the tibia, radius, and ulna 
(Figs. 140 to 143). These tumors often contain mucous cysts and 
spherical or branched osseous formations; they are circumscribed 
nodules, mostly forming in the medullary cavity, which gradually de- 
stroy the bone, but in such a way that new bone is constantly devel- 
oped from the periosteum, so that the tumor, even if very large, often 
remains covered entirely or partially by a shell of bone ; the diseased 



Fig. 142. 



Fig. 143. 





Central osteosarcoma of the lower jaw of a girl 
nine years old. 



Section of the specimen shown in Fig. 141. 



bone then appears puffed up like a bladder, and the tumor does not 
always cause a complete solution of its continuity. When these sar- 
comata occur in the lower extremity, they become very vascular ; 
numbers of small traumatic aneurisms develop in them, and a true 
aneurismal murmur may be heard in them, so that they are often con- 
sidered and described as true bone-aneurisms. The cystosarcomata 
and compound cysts, which are occasionally seen in bones, especially 
in the lower jaw, also in large hollow bones, have usually developed 
from osteosarcomata (Fig. 144). Central osteosarcomata are usually 
solitary, very rarely generally infectious. In the lower or upper jaw 
they are apt to come at the time of the second dentition, rarely at 
the first : in the long bones I have only seen them at middle age ; of 
the tumors called epulis (the word means located on the gums) a 



SARCOMATA. 



657 



Fig. 144. 



large number belong to these giant-celled sarcomata ; their location 
on the gums is generally only apparent ; they usually spring from 
cavities in the teeth, and have 
started from carious roots of teeth. 
Some also call epithelial cancer 
epulis ; it is well either not to use 
such terms or to restrict them by 
certain adjectives ; as sarcomatous, 
fibrous, carcinomatous epulis, etc. 
Peripheral osteosarcomata or peri- 
osteal sarcomata (osteoid-chondro- 
mata of Virchow) are quite ma- 
lignant; they either have granula- 
tion structure with osteoid tissue 
as in osteophites, and are partly 
ossified ; or they are very large- 
celled myxosarcomata, also part- 
ly ossified. The rapidity of the 
course varies greatly; sarcomata 
of the lungs have been observed 
after them. 

Spindle-celled sarcomata are 
found especially often in muscles, 
fasciae, and cutis ; they are locally 
very infectious, and often return 
after extirpation. Myxosarcomata 
come in the cutis and subcutaneous 
cellular tissue, and with the naked 
eye are often difficult to distin- 
guish from cedematous soft fibromata, 
often the seat of multiple sarcoma, 
tumors have grown, and the more " medullary " their appearance, the 
more dangerous they are. I find that all ages, except perhaps child- 
hood, are equally disposed to these tumors. 

When sarcoma develops in a gland it almost always contains glan- 
dular elements, which may be greatly changed in form, and some of 
which may be newly formed. Hence, pure adenomata (which are 
very rare) may be difficult to distinguish from sarcomata that have de- 
veloped in glands (adeno-sarcomata). Glands are by no means equally 
disposed to the development of sarcoma ; we shall briefly state the 
localities where they are most frequently found. 

The female mamma, more than any other gland, is subject to these 
tumors. Sarcomata of the mamma are roundish, lobular, nodulated 
42 




Compound cystoma of the thigh, after I'ean. 

The nerves also art, relatively 
The more rapidly the primary 



TUMORS. 



Fia. 1-15. 



Fig. 146. 




Periosteal sarcoma of the tibia from a boy, from the 
collection at the surgical clinic of the University 
at Berlin. 



Section of Pig. 146. 



tumors of firm, elastic consistence ; the disease may attack a large or 
small portion of the lobes of the gland ; as a rule, only one breast is 
attacked and only at one point; at other times, several small nodules 
occur at the same time in one gland. These tumors grow very slowly. 
cause no pain ; like all sarcomata, they are sharply bounded from the 
healthy parts, hence they are movable in the glandular parenchyma ; 
when they grow large (in the course of years they may attain the 
size of a man's head) they almost always form cystosarcomata ; in 
the course of time they become softer and cause pain ; ulceration also 
occurs. The anatomy of these tumors has always excited great inter- 
est. As the glandular elements, acini as well as excretory ducts, 
were found in them, it was formerly supposed that they had developed 
in the tumor ; hence these tumors were called partial hypertrophies 
of the mamma. I consider this view incorrect, and think that, by ex- 
amining a great many of these tumors, I have satisfied myself that pri- 
marily and chiefly there is a development of sarcoma in the connective 
tissue around the acini, the latter being preserved, although they may 
be changed in various ways. The distention of the gland-ducts causes 
cysts, at first slit-shaped, subsequently more roundish, with muco- 



SARCOMATA. 659 

serous contents, whose development we shall immediately follow. 
The tissue of the neoplasia itself is usually composed of small, round, 
spindle-shaped, rarely of branched cells, with considerable developed, 
fibrous, sometimes gelatinous intercellular substance. In some of 
these tumors the fibrous tissue may be so prevalent that, in consist- 
ence and constitution, the entire tumor may resemble fibroma. Acci- 
dental cartilaginous and osseous tissue are occasionally observed, but 
are very rare, and have no influence on the course of the disease. If 
the growth of these tumors were regular throughout, the excretory 
ducts and acini of the glands would be equally enlarged or compressed ; 
for, if you imagine a part of the gland, say a lobule, spread out as a 
surface, and suppose the basis to which this surface is attached en- 
larging, the epithelial surface must also enlarge. But the glands 
may be regarded as surfaces bulged out in many places, so that this 
representation is quite proper. Such a regular growth in all parts of 
a gland never or very rarely occurs ; the result is, that frequently only 
the excretory ducts elongate or enlarge much ; this induces the slit- 
shaped, elongated cysts, visible to the naked eye ; but, by simultane- 
ous distention of the glandular acini, roundish cysts are often formed. 
In this stretching of the sacculated glandular surface, the epithelium 
increases and develops to a higher stage, inasmuch as the small, round 
epithelial cells of the acini increase greatly, and change to a layered- 
cylindrical epithelium. The glandular substance thus altered secretes 
a muco-serous liquid, a very minute portion of which is spontaneously 
evacuated from the nipple, while most of it is retained in the tumor, 
and serves to dilate the already distended glandular cavity (retention 
and secretion cysts). 

Then the tumor-substance again grows into these cysts in the form 
of lobulated, leaf-like proliferations (cystosarcoma phyllodes, prolife- 
rum ; John Muller), so that the cut surface may thus acquire quite a 
complicated appearance. 

The relation of this cyst-development to the sarcoma (the nature 
and course of the disease is not much influenced by the former) varies 
greatly in these, as in all cystosarcomata. 

Mammary and cysto sarcomata are not very rare, but are far less 
frequent than the cancers of the breast, which we shall hereafter men- 
tion. The disease is most frequent in young married women, but 
also occurs shortly before puberty — rarely after the fortieth year of 
life. The growth of these tumors is very slow, and is painless before 
they become large ; later, however, they are accompanied by piercing 
pains ; as the tumor may grow as large as a man's head, and ulcerate, 
it may prove very troublesome. Some of these sarcomata have the 
peculiarity of swelling, and becoming slightly painful shortly before 



660 



TUMORS. 



and during menstruation. In this disease, the general health is not 
affected, except that in large ulcerated tumors the patients emaciate, 
become anaemic, and acquire a suffering look. The course of the dis- 



Fig. 147. 




From an adeno-sarcoma of the female breast : a, dilatation of the excretory ducts; 5, of the 
acini, magnified 60 diameters ; c, a dilated acinus of the mammary gland, with cylindrical 
epithelium ; intermediate substance resembling granulation-tissue, magnified 350 diameters. 

ease may vary ; there are not a few cases where small sarcomata of 
the breast, which perhaps came after the first confinement, spontane- 
ously disappeared in the course of time, or else remained for the rest 
of life without doing any harm ; but in most cases these tumors grow 
gradually, until they are operated for ; if this is not done till late, when 
the tumors have become large, and the women have attained old age, 
they may become infectious. In young girls and women, when a 
slowly-growing sarcoma of the mammary gland is extirpated, it does 
not usually reappear. If, however, the sarcoma first appears between 
the thirtieth and fortieth years, we have to fear general sarcoma infec- 
tion, or actual transformation to carcinoma by epithelial proliferation, 
I consider it advisable, in all cases, to extirpate these mammary sar- 



SARCOMATA. 661 

comata early, as we never know exactly what their future course will 
be. The diagnosis is often difficult; small, nodular, lobulated hard- 
enings may occur in the breasts from chronic inflammation, especially 
during and after lactation, which pass off spontaneously, or under the 
use of iodine. We often have to decide from the course whether the 
case is one of chronic inflammation which may subside, or an actual 
tumor. Even the most accurate anatomical examination is here of no 
avail, for young sarcoma-tissue cannot be distinguished from inflam- 
matory neoplasia. This is another case where the boundary between 
chronic inflammatory neoplasias and tumors cannot be accurately 
drawn. 

A second organ, in which adeno-sarcoma and adenoma develop, is 
the salivary gland. The tumors that form here are usually quite firm 
and elastic, are tolerably movable and grow very slowly ; they occur 
in the parotid more frequently than in the sub-maxillary gland, and 
very rarely in the sublingual. As seen by the naked eye, the anatomi- 
cal characteristics vary greatly ; the tumor is always distinctly bounded 
by a capsule, which is very intimately connected with the gland-tissue. 
The substance of the tumor may be of pulpy, cartilaginous or fibrous 
consistence, it may be ossified, or calcified ; it often contains cysts 
of briny, gelatinous, or serous fluid. Histological examination of these 
tumors shows that their softer parts consist of spindle-cells and stellate 
cells, sometimes with a slight, again, with a large amount of mucous 
or cartilaginous intercellular substance ; there are also newly-formed 
gland-tubes. In rare cases, the tumor consists almost exclusively of 
cartilage, but very frequently there is some sarcomatous tissue present. 
These tumors may develop from the time of puberty to the fortieth 
year ; they grow very slowly and painlessly, and particularly slowly 
when they do not form till middle age. Although they never retro- 
grade, small tumors (say as large as an egg) of this variety may cease 
growing late in life. If these tumors be extirpated from young pa- 
tients, as a rule, they do not return. But later in life they often recur 
after extirpation, and return so quickly, that they gradually grow 
deeper in the neck, and finally become inaccessible to the knife ; the 
neighboring lymphatic glands of the neck are infected, and the disease 
assumes the character of carcinoma ; the adeno-sarcoma becomes cancer 
of the gland. General development of sarcoma scarce!) 7 takes place 
from these tumors. From the course above described, we might form 
the rule of removing these tumors early in young patients, but in older 
ones of not being too hasty about extirpation, as rapid recurrence is 
to be feared, while occasionally the primary tumors grow slowly. Sar- 
Domata of the salivary gland are not frequent. Similar myxo-sarco- 
mata and myxo-chondromata occasionally develop in the oral mucous 
membrane. 



662 TUMORS. 



9.— LYMPHOHATA. 

These neoplasias are very difficult to define accurately. According 
to the mode of development we may assume a secondary inflammatory 
swelling of the lymph-glands from infection, and an idiopathic hyper« 
plasia. In diseases from the most varied causes, the lymphatic glands 
almost always present a similar appearance ; they are enlarged, more 
succulent, firmer than normal. The microscopic examination of lym- 
phoma shows the following appearances, if made from a hardened, 
properly-prepared specimen : All the cellular elements are multiplied 
and enlarged ; the lymph-cells in the alveoli, the connective-tissue 
cells of the trabecular, the capsules of the alveoli and the net-work ; 
thus, the structure of the gland is gradually lost entirely ; the whole 
organ becomes a mass of lymph-cells, although a fine net-work is gen- 
erally preserved, into which the hard connective tissue of the capsule 
and of the trabecular is also transformed, while the blood-vessels are 
preserved, and their walls greatly thickened (Fig. 148) ; the cellular 
infiltration may be so great, that an exact distinction between lym- 
phoma and glio-sarcoma (Fig. 148) may be impossible at some points. 
Usually there are glands of various sizes, and we find the large ones 
of the same structure as the smaller. Neither the macroscopic nor 
microscopic appearances will determine exactly the causes of the 
hyperplasia, whether it be idiopathic or due to chronic inflammation ; 
we can only say, in general, that glands much enlarged by chronic 
inflammation more frequently contain abscesses and caseous foci than 
those which are apparently idiopathic hyperplasia. Perhaps I am too 
conscientious in using the term " idiopathic disease of the lymphatic 
glands ; " for in many of these cases we can discover no peripheral irri- 
tation, although many things speak in favor of the disease of the 
glands being secondary ; it is possible that slight, temporary inflam- 
mations have existed, that have excited disease of the glands, and 
have disappeared before the affection of the glands has shown itself. 
We formerly spoke of a similar secondary plastic process in the lym- 
phatic glands, after the primary peripheral irritation had ceased, as 
being a chief symptom of scrofula ; hence we might term Iymphomata 
as typical scrofulous tumors (scrofulous sarcoma, JB. vo)i Langenbecti). 
Let us study them further, anatomically and clinically. 

For a long time the glands preserve their kidney-shape till finally, 
as they continue to grow, this also is lost, and the adjacent glandular 
tumors unite to form a lobulated mass. To the naked eye, the extir- 
pated tumors appear roundish, oval, or kidney-shaped ; on section, 
they are of a light, grayish-yellow color, which, on exposure, changes 



LYMPHOMA T A. 
Fig. 148. 



663 




From the cortical layer of a hyperplastic cervical lymphatic gland. Magnified 850 diameters, a 
a, section of vessels with thickened walls, brushed-out alcohol preparation. 

to a yellowish-red. These tumors are firm and elastic ; they are easily 
diagnosed, from their locality. All lymphatic glands are not equally 
disposed to this disease ; the most frequently affected are the cervical 
either on one or both sides ; more rarely the axillary and inguinal, 
most rarely the abdominal and bronchial. These tumors are hardly 
ever congenital, but they may occur from the first to the sixtieth year, 
although they are most frequent between the eighth and twentieth. 
Not unfrequently, hyperplasia of the lymphatic glands is multiple ; 
but only one or a few glands in the neck may be affected ; if this be 
the case, the tendency to such neoplasia runs out in the course of 
time, while the tumors which have grown painlessly, and continued 
free from pain, have their growth arrested, and may be carried till 
death. In rare cases, the new formation appears almost at the same 
time in all the lymphatic glands of one or both sides of the neck, so 
that the latter is thickened, and the movements of the head are much 
impeded ; if these tumors continue to grow, they finally compress the 
trachea and cause death by suffocation ; but even in these severe casea 
there is occasionally a spontaneous arrest of the disease, and then even 
large tumors of this kind may be successfully extirpated ; some of 
these glands, too, are finally destroyed by ulceration and caseous de- 
generation. 

The worst cases are those where the tumors quickly grow to large 
medullary tumors (not unfrequently under the form of fasciculated 
medullary fungi), and where the neighboring tissue is also changed 
to lymphoma. Patients with such tumors rarely escape ; anaemia comes 
on, the nutrition is impaired, and hypertrophy of the spleen may 
appear, and the patient die of excessive anasmia and marasmus. These 
malignant lymph omata, which Lucke calls lympho-sarcomata^ cannot 
be anatomically distinguished from the benignant forms. But they 



63 4 TUMORS. 

may be recognized from the fact that they proliferate rapidly, and 
especially that they unite with the parts immediately around. It 
seems to me they are certain to recur, and are the most dangerous of 
tumors. Quite recently I saw two cases where autopsy revealed me- 
tastatic lymphomata in the lungs and spleen. 

In some of these cases of lymphoma, typical leucocythemia has 
been observed, and Virchow thinks that in these cases the increase 
of white corpuscles in the blood is due to the excess supplied by the 
hyperplastic lymphatic glands. I do not entirely share this view, first, 
because even with extensive tumors of the lymphatic glands leucocy- 
themia is rare, and secondly, because it is very improbable that, when 
their normal formation is entirely destroyed, the lymphatic glands 
should continue their functions physiologically, or even in excess. As 
Frey, 0. Weber, and myself, have made a number of unsuccessful 
attempts to inject the lymph-vessels of such glands, this also would 
favor the view that these hypertrophic lymphatic glands are physio- 
logically insufficient, although in lymphatic glands especially such 
negative results at injection are to be very carefully judged. The 
fact that Muller (in Jena) succeeded in injecting a small, slightly- 
swollen gland, of course proves nothing, as the destruction of the 
lymph-ducts only comes on gradually. However, the interesting fact, 
that leucocythemia occurs especially with enlargement of the lymphatic 
glands and spleen, is not to be denied, only the connection is not so 
direct, there must be some other cause at present unknown, for the 
development of this disease. 34 

What has been said shows that the prognosis of lymphoma varies, 
and can only be pronounced with any certainty after a period of ob- 
servation of the rapidity of its growth ; in general terms, we may say 
the disease is the more dangerous the younger the patient. I have 
rarely seen it develop after the thirtieth year, and formerly thought it 
hardly occurred after that ; but not long since I met a case of large 
lymphoma of the bronchial glands in a stout woman, forty-five years 
old, who had suffered for five years from asthma ; the disease had 
finally induced suffocation. In another case, in a man sixty-five years 
old, there was immense lymphoma of the axillary glands. 36 

The treatment of this disease of the lymphatic glands will at first 
often be internal, usually antiscrofulous — cod-liver oil, brine-baths, 
and, if the constitution of the patient does not contraindicate it, iodine 
remedies ; if there be considerable anaemia, iron alone, or with iodine, 
is indicated. In favorable cases, recent lymphomata disappear under 
this treatment. In still other favorable cases, we arrest the growth 
of the tumor ; but, unfortunately, the number of cases curable by med- 
cine is slight, and in those very cases, where we wish most from these 



LYMPHOMATA. 665 

miernal remedies, because the tumors are too large for operation, they 
often fail entirely ; indeed, I have even observed injurious effects 
from energetic iodine treatment in rapidly-growing tumors of this 
variety, in the shape of rapid softening of the larger part of the tu- 
mor, accompanied by severe febrile symptoms. Lucke made paren- 
chymatous injections of tincture of iodine with good results ; under 
this treatment I have seen small abscesses and insignificant contrac- 
tions occur, but no entire disappearance of the tumor. My experi- 
ence with the constant current has been about the same. Of external 
remedies also, iodine is the most effective, mercury scarcely at all so. 
Favorable results have also been attained by JBaum from compression 
with apparatus prepared for the special cases. I have thus caused im- 
provement ; occasionally, a slight diminution, or partial suppuration, 
but never perfect cure. We can only expect a cure from operation in 
those cases where the disease of the glands has run its course. It is 
true that, when these tumors lie very close to the trachea, we are oc- 
casionally obliged to operate on them when in full growth, but we 
must then always expect local recurrence or disease of other groups 
of glands. A careful consideration of all the circumstances must de- 
termine in any given case whether an operation will probably be suc- 
cessful. The operation itself will be well borne in cases where the 
glands may be isolated, and still preserve their capsules. I have ex- 
tirpated (or rather dug out with my finger) twenty or more isolated 
glands from the neck of the same patient without subsequent recur- 
rence ; but when the glands unite to one mass, and are soft, it is on 
the one hand a sign of rapid growth, and local recurrence may be cer- 
tainly expected ; on the other hand, it will greatly increase the diffi- 
culty of operation. Sometimes lymphomata, developing deep in the 
neck in young, otherwise healthy persons, grow behind the jaw into 
the throat and implicate the tonsils and pharynx ; they usually soon 
prove fatal ; the operations that might relieve them are so dangerous 
that they rarely prolong life. 

Of the other glands, which, according to recent observations, are 
to be classed in the lymphatic-gland system, the tonsils alone are 
subject to hyperplastic disease ; but this hypertrophy of the tonsils 
which is common, and in children and young persons is quite fre- 
quent, more resembles chronic inflammatory secondary swelling of the 
lymphatic glands ; it is usually the result of chronic catarrh of the 
pharynx, while the reverse is often falsely considered to be the case, 
namely, that the hypertrophied tonsils are the cause of the pharyngeal 
catarrh ; hence, in such cases, extirpation does nothing for the chief 
trouble, the frequent inflammations of the throat. 



666 TUMORS. 

Hypertrophy of the thymus gland does occur, but is rare. The 
analogous diseases of Peyer's glands and the spleen have no special 
interest in surgery. 

Lymphoma also occurs in tissues which do not belong to the lym- 
phatic glands. I class as lymphomata all those medullary tumors, 
usually soft, in which, by hardening and preparation, we may see a 
net-work analogous to that of the lymphatic glands. In this sense, I 
have seen lymphomata of the upper jaw, scapula, cellular tissue, eye, 
etc. ; tumors whose structure frequently can only be imperfectly dis- 
tinguished from granulation sarcoma (especially from Virchoufs glio- 
sarcoma), and which form their ordinary medullary consistency, are 
briefly called " medullary fungi." According to my experience, the 
mixture of the above forms has no special prognostic significance, as 
these tumors are alike malignant and infectious ; but the importance 
of the most accurate examination of these tumors should not on this 
account be limited or undervalued ; during the last ten years we have 
learned interesting and important clinical differences for the more ac- 
curate distinction between sarcoma and carcinoma. Ten years ago 
we could not have spoken as decidedly about sarcoma and lymphoma 
as we now may. What we now include under " lymphomata " were 
formerly treated of partly under glandular hyperplasias, partly as sar- 
comata, partly as medullary fungi. 



LECTURE XLIX. 

10. PapUlomata. — 11. Adenomata. — 12. Cysts and Cystomata. — Follicular Cysts of the 
Skin and Mucous Membranes. — Neoplastic Cysts. — Cysts of the Thyroid Gland. — 
Ovarian Cysts. — Blood-Cysts. 

10. PAPILLOMATA— PAPILLAEY HYPEETEOPHY. 

Hitherto we have spoken exclusively of new formations from the 
series of connective-tissue substances, muscles and nerves. "We now 
pass to the neoplasias of true epithelium, derived from the upper and 
lower germ-layer of the embryo. 

The epitheliums form a great part of two normal tissues, namely, 
of the papillae (tufts, intestinal villi), and of the glands; the former 
are wavy or finger-like elevations, the latter pouched or cylindrical 
sinkings in of the membranes, which the epithelial covering accurately 
follows. Both give the physiological paradigms for certain forms of 
tumors, of which we shall mention the purely hyperplastic forms of 
the first series, papilloma, and those of the second series, adenoma, 



LYMPHOMATA, PAPILLOMATA. 



607 



Both are accompanied by corresponding connective-tissue and vas- 
cular neoplasia. 

Horny papillomata come exclusively in the cutis, rarely in the 
walls of sebaceous cysts. We may distinguish two chief forms : 

(a.) Warts. Anatomically these consist of an excessive growth in 
length and thickness of the papillae. The epidermis on these abnor- 
mally large papillae homines in the form of small rods, of which every 
wart is composed, as you may readily see with the naked eye (Fig. 
149). These warts which, without any known cause, appear espe- 
cially often on the hands in great numbers, are rarely larger than len- 
tils or peas. 

Fig. 149. 




Wart: a, longitudinal section : b, cross section. Magnified 20 diameters. 



(b.) Horny excrescences are to some extent large warts ; the epi- 
dermis of the enlarged papillae adheres to a firm substance, which in- 
creases enormously, so that the horn, whether it be straight or twisted, 
may grow to three or four inches or more. Although externally these 
horns greatly resemble those of some animals, their anatomical struct- 
ure is different, for the latter always have a basis of bone. Horny 
excrescences are of a dirtj'-brown color ; they occur chiefly on the 
face and scalp, but may also come on the penis and other parts of the 
body, and occasionally they grow from atheroma-cysts. 

The development of warts and horny excrescences is evidently due 
to a general tendency of the skin that way. This is chiefly evident 
from the fact that as many as twenty or thirty warts often occur on 
the hands, especially of children shortly before puberty. Irritating ex- 
ternal influences, affecting the hands particularly, apparently combine 
with the fact that the epidermis on the hands is normally very thick 



068 TUMORS. 

The tendency to horny excrescence, rare as it is, rather belongs to ad- 
vanced age, just as most of the other epidermoid neoplasia?, of which 
we shall hereafter speak. Anatomically, hystricismus would also be- 
long to the above forms of horny growths. Hystricismus , or porcupine- 
disease of the skin, is a peculiar variety of papillary hypertrophy, with 
hornifying of the epidermis of such a nature that porcupine-like 
formations develop on the cutis. Like ichthyosis (a scaly thickening 
of the epidermis over the whole body), this affection is mostly congen- 
ital ; but I have seen analogous formations in some forms of elephan- 
tiasis nostras. 

The predisposition to warts is entirely devoid of danger, and in 
many cases ceases spontaneously. Popularly, warts are considered 
contagious, possibly not altogether without reason. I saw a case 
where an ordinary wart formed on the side of a toe, and, on the 
part of the neighboring toe lying in contact with it, another wart 
formed. Horny excrescences are more important; although they occa- 
sionally break and fall off spontaneously, they grow again if they are 
not operated upon ; indeed, in some cases epithelial cancer forms at 
the point where a horny excrescence was located. 

In most cases warts may be left to themselves. As in all dis- 
eases that recover spontaneously in the course of time, there are 
numerous popular remedies : old women regard the placing of a 
hand covered with warts on the hand of a corpse, or rubbing it 
with various leaves and weeds, as sovereign remedies. If you wish 
to get rid of certain large warts that are peculiarly annoying to their 
owners, it may best be done by caustics. For this purpose I use 
fuming nitric acid, applying it to the wart and the next day cutting 
off the cauterized portion till a drop of blood flows, then repeating 
the cauterization. This should be continued till the wart has entirely 
disappeared. 

Horny excrescences can only be cured radically by cutting out the 
piece of skin on which they are located. 

By soft, sarcomatous papittomata, we mean those neoplasia? that 
have the form of papilla?, consist of soft connective or sarcomatous 
tissue, and are covered by an epithelial coating analogous to that of 
the matrix. 

Sarcomatous papillae (soft warts) occur rarely on the cutis, but 
occasionally appear congenitively on one side of the face as cock's- 
comb-like proliferations. The broad and also the pointed condylomata 
on the mucous membranes are products of syphilis and of the specific 
irritating pus of gonorrhoea ; we do not class them among tumors. 

Sarcomatous papillomata develop much more frequently on the 



PAPILLOMATA. 669 

mucous membranes, especially on the portio vaginalis, more rarely in 
the rectal and nasal mucous membrane. According to the surgical 
nomenclature hitherto in use, they come in the category of mucous 
polypi. They are often complicated tumors, in which proliferation 
and ectasia of the glands, formation of sarcomatous intermediate sub- 
stance, and papilloma, all go together. They are mostly pedunculated 
tumors ; occasionally a large surface of mucous membrane becomes 
diseased at the same time. 

These papillomata are rarely infectious, but they occasionally recur 
after extirpation. The extensive papillomata that occasionally occur 
in the larynx in children are perhaps always of syphilitic origin. 

I formerly called tumors with papillary formation, which developed 
from vitreous mucous tissue, cylindromata ; but this formation is not 
so characteristic as I formerly supposed ; it occurs both in sarcomatous 
and carcinomatous tumors. Fibromatous and sarcomatous papillae 
may develop on the inner surface of cysts. 



11. ADENOMATA— PAETIAL GLANDT7LAE HYPEETEOPHY. 

New formation of genuine, regularly-developed glands or parts 
of glands is not frequent, although Ave shall hereafter learn that, in 
cancer, incomplete development of glands is one of the most common 
forms of neoplasia. 

Although sarcoma of the mamma was often spoken of as partial 
hyperplasia of the gland, because glands were found in it, of late it 
has appeared doubtful whether gland-acini were really developed in 
the tumors formerly described as adenosarcoma (page 657) ; from my 
own observations, I must consider true adenoma of the breast as 
very rare ; I have only seen it once, it was then in a tubular form. 
Forster and others, however, describe acinous adenoma of the mamma ; 
on account of this rarity, not much can be said about the prognosis 
of these tumors, which usually remain small. They are generally con- 
sidered as entirely benignant ; but, on anatomical grounds, it seems 
to me probable that they cannot differ so much in prognosis from 
carcinoma. 

So far as my investigations go, the so-called hypertrophy of the 
prostate is never accompanied by development of adenoma, but onlv 
by ectasia of the acini and epithelial hyperplasia ; the frequently-ob- 
served enlargement of this gland depends essentially on diffuse or 
nodular myoma (page 637). 

The glands of the skin and some mucous membranes may also give 



670 



TUMORS. 



rise to development of adenoma and adenosarcoma ; it is said that 
tumors of the skin, which are to be regarded as pure adenomata, may 
result from the glandular epithelium, analogous to the gland-develop- 
ment in the foetus. Verneidl first described an adenoma of the sweat- 
glands. I have never observed such tumors, but do not doubt their 
existence, since Hindfleisch has demonstrated to me an adenoma of 
this variety. Those glandular formations that occur in the mucous 
membrane of the nose, rectum, and uterus, and wmich are embedded 
in a gelatinous, oedematous connective tissue, more rarely in some 
other form of sarcoma-tissue, are more frequent. 

Fig. 150. 




From a mucous polypus (adenoma) of the rectum of a child. Magnified 60 diameters. 



Tumors are thus developed which, in general terms, are called 
mucous polypi : sometimes they are in broad folds, sometimes nodular 
pedunculated tumors; they have the color and consistence of the 
mucous membrane whence they spring, are also covered with its epi- 
thelium, except only the soft polypi of the external auditory meatus ; 
strange to say, these are sometimes covered with ciliated epithelium. 
All of these mucous polypi do not contain glands ; they are usually 
absent from the aural polypi and the small, leaf-like proliferations of 



ADENOMATA. 67 1 

the female urethra, the so-called urethral caruncles. The latter neo- 
plasise consist solely of cedematous and gelatinous connective tissue, 
with an epithelial covering. Most mucous polypi of the nares, large 
intestine, and especially of the rectum, consist to a great extent of 
elevated and also newly-formed glands of the mucous membrane, 
whose closed ends sometimes dilate to mucous cysts. Hence, in the 
anatomical system, according to the glands they contain, mucous 
polypi may be classed among pure adenoma (as rectal mucous polypi 
in children), among adeno-sarcomata (many nasal mucous polypi), 
among cedematous fibromata, or, lastly, among the myxosarcomata. 
The predisposition to mucous polypi reaches from infancy to the fiftieth 
year. In children the disease is limited to the rectum and large intes- 
tine, where sometimes one, sometimes several tumors of the same sort 
develop, but the latter occurs even oftener in adults than in children. 
From puberty till about the thirtieth year, it affects chiefly the nasal 
mucous membrane ; sometimes giving rise to single polypi, again, to 
proliferations in both sides of the nose ; the latter is the more frequent. 
Toward the thirtieth year, mucous polypi of the uterus occur ; under 
some circumstances they may change to cancer. In all of these 
polypi there is a great tendency to recurrence, especially in those of 
the nose, which often do not cease growing till they have been re- 
moved three or four times. Generally, in the course of years, the 
disposition to these new formations ceases spontaneously, and they 
cease to recur, or the smaller ones even cease to grow, as, for instance, 
in the uterus. Microscopic examination of these tumors may give 
some clew to the prognosis, inasmuch as those tumors, which consist 
entirely of oedematous connective tissue have far less tendency to re- 
cur than those which consist of tissue analogous to inflammatory new 
formation ; lastly, in some cases anatomical examination alone can 
prevent mistaking them for epithelial carcinoma. 

Mucous polypi of the nose are most readily removed by tearing them 
out with the forceps made for that purpose ; we do the same for those 
of the external auditory meatus [the latter may be most effectually cured 
by free applications of liquor ferri persulphatis] ; those of the uterus 
and rectum we may cut off at the base with scissors ; if we fear haemor- 
rhage, we may previously apply a ligature, or employ the ecraseur. 

Of the glands without excretory ducts we shall here consider only 
the thyroid, as it is a true epithelial gland ; adenoma of the ovary so 
often becomes cystoid in form, that it may be more suitably treated 
of in the next section. Tumors of the thyroid gland have long been 
called goitre, struma (in the middle ages " strumous " indicated what 
we at present call "scrofulous"). Considering the anatomical rela- 



672 



TUMORS. 



tion of these tumors to the gland, we find that there are diffuse swell 
ings of the gland, affecting one or both lobes, and others that are dis- 
tinctly bounded in the gland, the latter remaining normal or but 
slightly hypertrophic. If we exclude simple cysts of the thyroid, so- 
called struma cystica, most other forms of goitre are pure adenoma or 
cysto-adenoma. If the tissue of these tumors, which may vary greatly 
in consistence, be not metamorphosed by secondary changes, on section 
it appears to the naked eye almost the same as the cut surface of a 
normal thyroid gland. Microscopically also it is very much the same; 
almost all thyroid tumors on microscopic examination show a large 
amount of connective-tissue capsules, which contain a clear gelatinous 
substance filled with more or less round pale cells (Fig. 151). The 

Fig. 151. 




From an ordinary firm tumor of the thyroid— adenoma of the thyroid ; partial injection. 
Magnified 100 diameters. 



size of these varies greatly, the youngest, which as yet contain no 
gelatinous substance, but only cells, being analogous to the foetal 
thyroid vesicles, while the larger are six or ten times this size. One 
of the most frequent changes in goitre-tumors is the formation of 
cysts, which come from a number of the dilating gland-vesicles uniting, 
and their thick gelatinous contents becoming fluid. But, besides this 
formation of cysts in goitres, there are other just as frequent changes 
that occur almost regularly if the goitre exists a long time: these are 
extravasations of blood, which are mostly reabsorbed, but leave more 
or less pigmentation. Caseous and fatty degeneration is also frequent 
in old goitres ; lastly, calcareous degeneration often occurs, so that by 
these secondary changes the original picture of the tumor may be 
much altered. Goitrous tumors, which may lie in the middle of the 



ADENOMATA. 673 

neck or to both sides, in numbers or solitary, may attain a consider- 
able size, compress the trachea, and cause suffocation. Much more 
rarely the regular double-sided hypertrophy of the thyroid attains a 
dangerous size. Goitre is chiefly remarkable for its endemic occur- 
rence ; it is found mostly in mountaineers : it is seen in the Hartz, 
Thuringian, Silesian, and Bohemian mountains, and in the Alps, 
although not equally frequent in all parts. Some valleys of Switzer- 
land and of the Austrian Alps are entirely free from it. It has been 
ascribed to the most different causes, especially to the water and soil, 
without any definite scientific reason having been found by accurate 
investigations. Undoubtedly, climatical and geological conditions 
have much to do with this disease. Complete similarity in the con- 
stitution (probably often hereditary) of goitrous patients can hardly 
be proved ; a certain connection with cretinism cannot be denied, in- 
asmuch as most cretins have goitre ; but the disease is more frequent 
in persons with well-developed bones and brain. Goitre may be con- 
genital in some rare cases, but does not usually increase till the com- 
mencement of puberty ; the growth rarely continues beyond the fiftieth 
year ; goitres which have continued harmless till then, usually cease to 
grow, and subsequently cause no trouble ; to this rule there are only 
a few exceptions, where cancerous goitre develops from the above 
hyperplastic form, infecting the neighboring lymphatic glands ; these 
almost always prove fatal by suffocation. It is scarcely necessary to 
consider struma aneurysmatica as a peculiar variety, as it is merely a 
goitre accompanied by great dilatation of the afferent arteries. Prep- 
arations of iodine are usually employed against this disease ; they are 
only efficacious, however, at the commencement; later they are almost 
useless ; they are, however, used both internally and externally, as we 
have no other remedy. Extirpation of hypertrophied thyroid glands, 
as well as of large goitrous tumors, is very dangerous ; it is often fol- 
lowed by severe haemorrhage or occasionally by sudden death from the 
extent of the operation, so that we should only try it in small movable 
goitres in young persons. Even then the operation is occasionally 
dangerous, and some experience is necessary to tell beforehand which 
tumors can be safely operated on. In general, I would warn you 
against performing such operations for the cosmetic effect ; if there be 
danger of suffocation, we may be obliged to try even doubtful opera- 
tions. The best chances are offered by movable goitrous tumors in 
the median line of the neck in young persons, while the removal of 
even small ones deeply embedded in the hypertrophied lateral lobes 
is difficult and not free from danger. Even the slightest operations of 
this sort must be pei formed with the greatest care, especially in regard 
43 



674 TUMORS. 

to arresting the haemorrhage from arteries and veins (by mediate liga- 
tion before their division) ; in detaching the encapsulated tumor it is 
better to use the finger, a probe, or some other blunt instrument, than 
the knife or scissors. 36 



12. CYSTS AND CYSTOMAT A— CYSTIC TUMORS. 

A tumor formed by a sac filled with fluid or pulp is called a cyst 
or cystic tumor. It may develop from a sac already existing (cyst), 
or it may develop entirely new (cystoma). If the tumor be formed of 
a convolution of very many such cystic tumors, it is called a a com- 
posite cyst or cystoma." If in one of the tumors already described, or 
in carcinoma, we find cysts also forming an essential part of the tumor, 
we give them names like cysto-fibroma, cysto-sarcoma, cysto-chon- 
droma, cysto-carcinoma, etc. 

As previously stated, Virchow reckons encapsulated extravasations 
of blood, hagmatonia (extravasations-cysten), among the tumors, as he 
also does dropsical effusions and hypersecretions of serous sacs (hy- 
drocele, meningocele, dropsy of the joints, .ganglion, etc., exudations- 
cysten). According to J^irdiow, the retention-cysts form the third 
class of cystic tumors. Of these, we leave the retention-cysts of the 
large canals, such as hydrops vesicas fellas, processus vermiformis, 
tubarum, and of the uterus, to internal medicine and obstetrics, and 
confine ourselves to those tumors that Virchow has grouped under 
the name of follicular cysts. The glands of the skin, as well as of the 
mucous membrane, have a tendency to the formation of cysts. Cysts 
of the thyroid have a doubtful position between exudation, follicular 
and neoplastic cysts. Closed follicles of lymphatic glands seem 
never to give rise to cysts. 

Among the glands of the cutis, cysts develop from the sebaceous 
alone ; I do not know that cysts of the perspiratory glands have ever 
been described. The reasons for secretion collecting in the sebaceous 
glands are : (a) its becoming inspissated ; (h) closure of the excretory 
duct. If from either of these causes the secretion be retained and 
collect in the gland, the pouched secreting surface becomes expanded 
to a simple sphere ; the collected secretion exercises a mechanical 
irritation on the surrounding connective tissue, which consequently 
becomes thickened and surrounds the secretion like a vesicle. If the 
sac, not yet grown large, can be evacuated by strong pressure, the 
small open cyst is called a comedo^ or " maggot." If, from any irrita- 
tive inflammatory process, the excretory duct of a sebaceous gland be 
closed, there may be atrophy of the gland, as after a burn with very 



CYSTOMATA. 675 

superficial destruction of the skin ; but in other cases the secretion of 
the gland continues, and it distends slowly to a large sac. Such cysts, 
filled with fatty pulp and epidermis, are called pap-bags (grutzbeutel), 
atheromata. On microscopic examination we find the pulp to consist 
of fat-drops, fat-crystals, especially cholestearine, epidermis-cells, and 
small plates. It has very varied color and consistence ; most athero- 
mata on the scalp, which develop at advanced age, contain a dirty- 
grayish brown, badly-smelling, pulpy, pasty, sticky substance. Other 
tumors of this sort, especially those that are congenital, on the fore- 
head, temples, or face, are filled with a milky or light-yellow pulp, 
which, under the microscope, shows little besides epidermis-scales 
and crystals of cholestearine. This form- of atheroma is called " chole- 
steatoma." The sacs of these cysts are usually thin, and are com- 
posed of connective tissue ; their inner surface is usually distinctly 
bounded by rete Malpighii, and is wavy, or elevated into papillae. I 
have found no other resemblance to cutis in these sacs, but others 
have found hairs and sweat-glands in them. The contents of these 
cysts sometimes become calcareous. Atheroma may rupture as a 
result of injury, or, very rarely, spontaneously ; the pulp is evacuated, 
the edges of the opening are everted, and the inner surface of the sac 
becomes a bad-looking, ulcerated surface ; except on the head and face, 
where they are frequent, these tumors rarely occur. 

In the neck, salivary ducts (closed internally and externally, but 
open in the middle, which are lined with epidermis) may, in the course 
of years, become large cholesteatomata by the deposit of epidermis. 
These show themselves in the mouth (as ranula), or externally on the 
neck above and behind the thyroid. 

In the mucous membranes, also, inspissation of the glandular mucus 
and consequent hinderance to its evacuation, may cause development 
of mucous cysts ; but probably the more frequent cause of retention- 
cysts here is closure of the excretory duct. The secretion in these 
glands is usually a tenacious, often thick mucus, of a honey-color (me- 
liceris), reddish yellow, or even chocolate-brown. On microscopical 
examination of the contents of the cyst, we find numerous large, pale, 
round cells, often containing fat-globules, in homogeneous mucus, also 
cholesterine crystals, often in large quantities. In the nasal mucous 
membrane these cysts are rare, but they occur in nasal mucous polypi, 
often to such an extent as to give them the name of cystic polypi. 
LuschTca often found small cysts in the mucous membrane of the 
antrum Highmori. In the oral mucous membrane they occur chiefly 
on the inside of the lips, more rarely on the cheeks ; they are an ordi- 
nary occurrence in the uterine mucous membrane and in uterine 
polypi. In the rectal mucous membrane, on the contrary, mucous 



676 TUMORS. 

cysts do not occur, and they are very rare in the mucous membranes 
deep in the body. 

Neoplastic cysts. These result mostly from softening of tissue 
previously diseased by cell-infiltration, or of firm tumor-substance. 
As soon as the new formation has separated into sac and fluid con- 
tents, in some cases a secretion from the inner wall of the sac begins, 
so that the softening cyst becomes a secretion or exudation cyst, and 
thus grows. Any tissue rich in cells may be transformed into a cyst 
by mucous metamorphosis of the protoplasm, or, as others express it, 
by separation of the mucous substance through cells, without any 
connection with development of mucous glands. In the foetus, we 
know there is a development of cavities (i. e., the joints) by mucous 
softening of the cartilage-tissue. In cartilage-tissue there is often a 
mucous softening of certain parts, by which chondromata with mucous 
cysts are developed. In the same way it is not uncommon for parts 
to become fluid and encapsulated ; the same thing occurs in sarcoma, 
especially in giant-celled sarcoma. The often slit-shaped, smooth- 
walled cysts, with serous or sero-mucous contents which occur in 
uterine myomata, are possibly enormously dilated lymph-spaces. 
Bone-cysts always originate by softening ; the often glistening 
smooth membrane lining such cysts may in the course of time 
actually secrete. 

While the above varieties of neoplastic cysts have no relation to 
gland new formations, those we are now about to mention develop 
from adenoma. The cysts of the thyroid, cystic goitre, already men- 
tioned (page 672), have a somewhat uncertain position in this series; 
uncertain because they are not due to newly-formed gland follicles or 
ducts, but to collection of mucous secretion in one of the thyroid vesi- 
cles. If we term the contents of these cysts secretion, as we might do 
for some reasons, we must class these cysts as retention-cysts. But, as 
it might be urged on the other hand that it would be questionable to 
speak of a secretion of the thyroid gland, as some state that normally 
the contents of the thyroid vesicles consist solely of cells, we may also 
consider the cysts resulting from softening of the contents of the vesi- 
cles as newly formed. Whichever view we take, it is certain that the 
cysts of the thyroid may be solitary, and may attain great size. More- 
over, in almost every large, and in some small, otherwise firm goitres, 
one or more cysts occur ; they usually have very smooth walls. The 
large, isolated cysts of this variety, particularly, give the impression 
that they are chiefly secretion-cysts, while other similar cavities in 
other parts of large goitres, by their softened, ragged walls, give the 
impression of being softening cysts. In the thyroid gland the process 
of softening usually terminates in the formation of a mucous fluid ; 



CYSTOMATA. 677 

but there are other cysts in these glands that contain a gray, friable 
pulp, which looks like that from sebaceous glands, but differs essen- 
tially from it because it contains only the detritus of thyroid tissue ; 
I have never seen genuine atheroma-pulp in thyroid cysts. 

Among the complicated cystic tumors are the cysto-sarcomata of 
the breast, of which we have already spoken (page 657), cystomata 
of the ovary and testicle, cysto-adenoma, cysto-sarcoma, and cysto- 
carcinoma. According to recent investigations, in the great majority 
of these cases there is a new development of gland follicles or ducts, 
from which terminal swellings become choked off, as results normally 
in the development of thyroid or ovarian follicles. A mucous wine- 
yellow, brownish-red, or dark-brown fluid is secreted in these newly- 
formed follicles (perhaps also in the normal ovarian follicles) ; this 
gradually distends the follicle, which was at first microscopic. Some- 
times immense ovarian tumors (distending the abdomen more than it 
is in the ninth month of pregnancy) may develop from such a follicle, 
or from the confluence of several of them to a common cavity. In 
other cases, hundreds or thousands of such follicles develop, forming 
the multilocular cystic tumors of the ovary. The latter process also 
occurs in the testicle, although more rarely than in the ovary. In 
both of these organs, as in the mamma and thyroid, the contents are 
mucous as a rule ; but, in the neoplastic follicular cysts of the ovary 
and testicles, there are occasionally secretion of fat and extensive pro- 
duction of epidermis ; these may remain as epithelial or epidermis 
pearls (cholesteatoma pearls, page 675), as big as a millet-seed or a 
pea, as I have seen them in tumors of the testicle, or form large cysts 
containing fat-pulp. The walls of these cysts, which are found the 
size of a child's head or larger, in the ovaries of old women, are usually 
more highly organized than those of cutis atheroma ; large quantities 
of hair, sebaceous glands, sweat-glands, papillae, even warty growths, 
are not unfrequently found in them. Indeed, plates of cartilage and 
bone, with teeth of varied form, have been found in these cysts, so as 
to render it probable that they were aborted foetuses from an incom- 
plete ovarian pregnancy. 

Besides occurring at the above positions, composite cysts are occa- 
sionally congenital about the sacrum ; they often contain ciliated epi- 
thelium, and, besides other tissues, they sometimes have glandular, 
follicular formations. The tissues in these congenital tumores coc- 
cygei vary from the relatively simple forms of cysto-sarcoma to the 
foetus infoetu, and cannot here be further entered into without going 
into details and fine discussion. 

I must lastly mention cysts containing perfectly fluid venous 
blood, and having smooth walls, which are here and there mentioned 



678 TUMORS. 

in literature. Some of them refill rapidly, others more slowly, after 
puncture ; such cysts have been observed in the axilla, on the thorax 
and neck. Excluding those cases where effusions of blood have given 
a dark blood-color to the mucous of serous contents of a cyst, and 
considering only those in which there is blood alone in the cysts, 
they could scarcely have been any thing but large sacs on the veins 
or cavernous-venous tumors whose framework had been entirely 
atrophied. All the cases of this kind so far reported have been 
cured by puncture and injection with iodine, so that nothing can be 
said of the pathological anatomy. 

The diagnosis of cystic tumor is easy ; if it can be certainly pal- 
pated, the fluctuation will be felt; deeply-seated cysts are often diffi- 
cult to recognize. They may be mistaken for other encapsulated 
fluids ; an exploratory puncture with a very fine trocar is admissible 
to confirm the diagnosis, if this be necessary to determine the treat- 
ment. There are various things for which a cyst may be mistaken ; 
e. g., cold abscesses are also painless, occasionally very slowly enlar- 
ging, fluctuating tumors ; also cystic parasites, of which two varieties 
occur in the outer parts of the body, especially in the subcutaneous 
tissue ; cysticercus cellulosaz and echinococcus hominis, although rare, do 
occur in the cellular tissue (and still more rarely in bone) ; the former 
is a small, the latter a large vesicle, which may contain many smaller 
ones ; the vesicle of which the animal consists always has a neo- 
plastic sac around it ; as may be readily seen, the whole thing gives 
the impression of a cystic tumor. I have seen cysticercus vesicles 
removed from the tongue and nose, echinococcus vesicles removed from 
the back and thigh. The diagnosis of cysts was made in all the 
cases except in one of the latter where abscess was diagnosed, and in 
fact, instead of the customary encapsulation, there was suppuration 
around the dead echinococcus vesicle. I have introduced this as a 
sort of appendix, because we have nowhere else an opportunity of 
considering the parasites. The millions of trichinae occasionally 
scattered through the muscles cannot be treated surgically, even 
when, according to the brilliant investigations of Zenker^ the diagno- 
sis may be, and has been, made in many cases. Dropsies of the sub- 
cutaneous-mucous bursas and of the tendinous sheaths as well as spina 
bifida may also be readily mistaken for cystic tumors, if we do not 
attend to the anatomical seat of these swellings. Cystomata may also 
be mistaken for other gelatinous soft sarcomata and carcinomata, and 
for very soft fatty tumors. As stated, when an intention of oper- 
ating renders a certain diagnosis necessary, we make an exploratory 
puncture. But what guides us chiefly, in the diagnosis, is the expe- 
rience about the relative frequence of different tumors on different 



OYSTOMATA. 679 

parts of the body ; I have given you the sum of these experiences in 
each form of cyst, and in the clinic shall hereafter direct your special 
attention to this point. 

As the above includes the prognosis of cystic tumors, all of which 
grow slowly when they exist as cysts without complication, we may 
pass at once to their treatment. We may remove cysts in two waj^s, 
viz. : by evacuating the contents, and locally applying remedies that 
may excite an inflammation which shall cause atrophy of the sac, or 
by extirpating the sac ; the latter is always the simplest and most 
rapid, and we always give it the preference where it can be done 
easily and without danger to life. But in cysts of the ovary, thyroid, 
and other glands, that are deeply seated or from other causes danger- 
ous, some other, safer operation is of course desirable, if it offers a 
prospect of success. We may induce shrinkage of the sac after pre- 
cedent evacuation of the contents, by a suppurative or by a milder, 
drier inflammation. If you slit up the wall of the cyst its whole 
length, and keep the cut edges apart, there will be suppuration and 
granulation of the exposed inner wall of the cyst, with detachment 
of the portions of tumor or epithelium clinging to it ; the sac then 
gradually shrinks up into a cicatrix, then decreases in size, and finally 
heals ; but this may require months. You may attain the same thing 
in a more subcutaneous way, by ligatures or tubes through the 
tumor at different points ; the irritation caused by these, as well as 
by the entrance of air, causes suppuration and granulation of the 
inner wall, and in favorable cases these may lead to atrophy ; often 
this does not occur in the manner desired, or else it may require 
months or years ; so that of these two methods the first is preferable ; 
it is particularly applicable to cysts of the neck. We may attain 
shrinkage of the cyst and drying up of its contents in another way, 
namely, by puncture, with subsequent injection of tincture of iodine ; 
we have already (page 525) said enough about the effect of this treat- 
ment. Here, too, the injection is followed by severe inflammation of 
the sac with sero-fibrinous exudation ; then the serum is reabsorbed 
and the sac contracts. The latter method is particularly applicable 
when we have to deal not with contents of softened tissue, but with 
a fluid secreted by the walls of the sac, that is, chiefly with cysts 
whose contents are serous, and some sorts of mucous cysts. Cysto- 
mata developed from softened gelatinous substance and fat-cysts are 
not suited for iodine injections ; for they are apt to be followed by 
severe inflammation and suppuration, with formation of gas, so that 
we are subsequently obliged to slit up the entire sac. And very thick 
walls, which contract very slowly or not at all, also contraindicate 
iodine injections. Hence among cysts of the neck we find some that 



680 TUMOKS. 

are suited for this treatment, others which are not, because their walls 
are too thick. Of the ovarian cysts, too, unfortunately but few are 
suited for treatment by iodine injection, so that recently the extirpa- 
tion of these tumors by laparotomy is considered the only certain 
operative proceeding ; of late years the results from this operation 
have constantly been growing more favorable. Lastly, we must state 
that in some cases it is best to avoid any operation ; for instance, I 
should consider it folly to persuade an old man, with a number of 
atheromata on his head, to have them removed ; for, if the operation 
were followed by erysipelas, it might prove fatal. 



LECTURE L 



13. Carcinomata. — Historical Eemarks. — General Description of the Anatomical Struct- 
ure. — Metamorphoses. — Forms. — Topography. — 1. Skin and Mucous Membranes 
with Pavement Epithelium. — 2. Milk Glands. — 3. Mucous Glands with Cylindrical 
Epithelium. — 4. Lachrymal Glands, Salivary Glands, and Prostate Glands. — 5. 
Thyroid Glands and Ovaries. — Treatment. — Brief Eemarks about the Diagnosis. 

13. CAECINOMATA— CANCEEOUS TUMOES. 

To give you an idea of how tumors were formerly diagnosed, and 
of the origin of many of the names still in use, I will read you a pas- 
sage from the classical, and, in its time, most prominent, work of 
Lorenz Heister, the third edition of which, published in 1731, I have 
before me. Here (page 230) it says : " The name scirrhus is given 
to a painless tumor that occurs in all parts of the body, but especially 
in the glands, and is due to stagnation and drying of the blood in 
the hardened part." (Page 318) " When a scirrhus is not reabsorbed, 
cannot be arrested, or is not removed by time, it either spontaneously 
or from maltreatment becomes malignant, that is, painful and in- 
flamed, and then we begin to call it cancer or carcinoma y at the 
same time the veins swell up and distend like the feet of a crab (but 
this does not happen in all cases), whence the disease gets its name ; 
it is, in fact, one of the worst, most horrible, and most painful of dis- 
eases. While the skin remains intact over it, it is termed hidden (can- 
cer occultus), but, when the skin has opened or ulcerated, it is called 
open, or ulcerated cancer ; the latter usually succeeds the former." 

It is not long since men lived in the simple belief that there was 
something real and truly practical in this mode of comparison and 
description. In a hundred years will they laugh at our present ana- 
tomical and clinical definitions, as we now do at good old Heister ? 
Who knows ? Time moves on w T ith giant strides ; things come to 



CYSTOMATA, CARCINOMATA. 681 

light, and, before we have time to look around, they are turned into 
history by the careful labors of energetic young experimenters. 

In the natural sciences we always dislike to give short definitions, 
because this is often impossible, on account of the passage of one pro- 
cess, or of one formation, into another. We may say that carcino- 
mata are very infectious tumors, and that this infection, which first 
attacks the lymphatic glands, afterward more distant organs, is prob- 
ably due to the passage of elements from the tumor (whether of cells 
or juice is not yet known) through the lymphatic vessels and veins 
into the blood. 

This common clinical definition of carcinoma should be controlled 
by the anatomical structure of these tumors. Anatomical peculiari- 
ties, easily recognized with the naked eye or with the microscope, are 
sought for. The classical monographs of Astley Cooper on diseases 
of the testis and breast (the latter, unfortunately, unfinished) show 
that, by a careful study of the points perceptible to the naked eye, a 
great deal may be attained by studying a single organ ; but a general- 
ization by aid of the anatomical preparations alone is impossible, as we 
have often felt, in the course of these lectures — it is frequently difficult, 
even with our present aids ; so that I cannot blame Virchow for try- 
ing, in his great work on tumors, to give most minute descriptions of 
the different forms of tumors at certain localities. Here, where we 
must express ourselves briefly, to give our descriptions an anatomical 
basis, we must be somewhat more decided and summary. When the 
naked eye no longer sufficed for the diagnosis of tumors, the aid of 
the microscope was invoked, and characteristic appearances were 
sought that might occur in the same way in all the tumors we have 
described. Still, whether the characteristics of the cellular elements 
were sought in their processes, the size of the nucleus or of the nucle- 
olus, the clinical and anatomical peculiarities would not always remain 
congruous. When the cells proved inefficacious as evidence of carci- 
noma, it was sought for in the general structure of the tumor ; alveo- 
lar formation was asserted to be the anatomical peculiarity. We 
even come in collision with this idea occasionally ; the net-like forma- 
tion of neoplastic lymphatic gland-tissue may also be termed " alveo- 
lar," and even acknowledging that the lymphoma net- work is so pecu- 
liarly characterized by its form that it may be readily excluded, there 
still remain some forms of chondromata and sarcomata, especially the 
giant-celled, and other large-celled sarcomata forms,- which we have 
already designated as alveolar sarcomata (pages 648 and 651), as the 
ghosts of cancer. 

Since anatomical study, especially the origin of neoplasms, has 
been regarded as an essential principle of division, we escape all the 



682 TUHOKS. 

difficulties just enumerated. Now, anatomy alone decides what is to 
be called cancer. In the clinic we then have to investigate how can- 
cers of different formations and compositions usually conduct them- 
selves : if they be infectious or not ; whether they run their course 
slowly or rapidly; if they are usually solitary or multiple; where 
most frequent, and how they are most successfully treated. Most 
modern pathologists agree in calling only those tumors true carci- 
nomata which have a formation similar to that of true epithelial 
glands (not the lymphatic glands), and whose cells are mostly actual 
derivatives from true epithelium. I am convinced that this view will 
constantly have more adherents, and that thus the differences about 
the anatomical definition of " carcinoma " will constantly diminish. 
Those investigators who, during the last few years, with all the mod- 
ern aids, have worked without prejudice on this portion of the study 
of tumors, recognize the great importance of epithelial proliferation 
in those tumors that we call cancer, still most of them seek for a 
compromise between the different histogenetic views, and wish still 
to admit, in a modified form, the development of true glandular and 
epithelial cells from connective tissue (heterology proper) (Mind- 
fleisch, Volkmann, Klebs, Lucke) ; only Thiersch, and recently Wal- 
deyer, maintain, as I do, the strict boundary between epithelial and 
connective-tissue cells. Waldeyer defines carcinoma as an atypical 
epithelial neoplasm. But we must here state that in cancer-tumors, 
besides the epitheliums, there are usually numerous young, small round 
cells which, infiltrated in the connective-tissue portion of the tumor, 
form an important part of it. This small-celled connective-tissue in- 
filtration, which exists in varying quantities wherever epithelial pro- 
liferations grow into the tissue, appears to be caused by a sort of re- 
action, and to be the result of the penetration of the epithelial new 
formations into the tissue, according to the number of infiltrated cells 
and their future fate, as well as the degree of vascularity, just as in 
inflammation it sometimes leads to softening, to atrophy, and cicatri- 
cial thickening of the tissue. In some cases this small-celled infiltra- 
tion is so considerable as almost entirely to hide the epithelial new 
formation (from which it may be very difficult to distinguish, if the 
latter be small). We may then be in doubt if it should not be re- 
garded as entirely independent, and occasionally, perhaps, as the sole 
constituent of cancerous tumors. Formerly I myself thought it neces- 
sary to agree to this, and even supposed that this component of car- 
cinoma possessed a spontaneous power of infection ; but further ob- 
servations with new aids have made it appear to me more probable 
that, even in the smallest cancerous nodules, epithelial elements are 
proliferating. The epithelial cells, and the base on which they grow 



CARCINOMATA. 683 

and from which they draw their nourishment, are most intimately 
connected. Many observations show certainly that the cellular infil- 
tration of the connective-tissue base causes an increased proliferation 
of the superjacent epithelium ; so it would not be difficult to suppose 
that the first impulse to the atypic adenoid proliferation was due to 
an irritative state of the epithelial base. But it is just as possible 
and probable that the epithelial proliferation is, as we usually con- 
sider it, the first formative process in the development of carcinoma. 
There can be no direct observation on this point ; the connective- 
tissue infiltration is always there as soon as the epithelial prolifera- 
tion ; this so much impedes investigation of the first stage, that a 
choice of very favorable objects (such as flat cancer of the skin) alone 
will give any evidence in favor of our view, while the study of more 
difficult objects (as infiltrated lymphatic glands) in which, during 
life, the most varied cells are mixed up, will find plenty of support 
for Virchoitfs view (which I formerly held), according to which epi- 
thelial cells may result from proliferation of connective-tissue cells. 37 

It is especially important, anatomically, to make a distinction be- 
tween adenoma and carcinoma, as the two forms of tumors have some 
points in common. Pure adenomata are composed of newly-formed 
gland-substance which is entirely analogous to or at least very much 
like the normal ; the connective tissue around the newly-formed acini 
has the same relation to them as to the normal. 

In adeno-sarcoma there is little if any new formation of glandular 
acini, but the sarcoma merely encloses the glandular spaces which 
have remained normal, or are dilated. But it is characteristic of car- 
cinoma that the epithelial covering of a skin or mucous membrane, or 
the epithelial lining of glandular cavities, grows into the skin, and 
even deeper, in the form of roundish nodules (acinous), or of round 
cylinders or rollers (tubular), just as occurs in the foetus. While so 
doing, the epithelial cells usually preserve their form, only they often 
grow much larger than normal. The form of the glands from which 
these formations proceed generally remains typical for the neoplasm 
also ; but it remains in irregular forms of glands, it is only rarely that 
cavities are formed, and that, actual secretion goes on in these cavities. 
Besides the epithelial parts of these tumors, the connective tissue, 
bones, muscles, etc., into which the epithelium enters, conduct them- 
selves as follows : We sometimes find them of normal, again of abnor- 
mal firmness, sometimes very soft, almost mucous, ordinarily in less 
quantity than the epithelial masses. It is usually pervaded by small, 
round (lymph) cells, often to such an extent that scarcely any fibrous 
tissue is left ; generally the infiltrated small cellular elements are scat- 
tered diffusely in the cancerous (connective-tissue) framework; very 



684 TUMORS. 

rarely, we find numerous cells, collected together in a fissure between 
the connective-tissue bundles. When the tumor advances into the 
bone, the latter is eaten away, as in caries. I have not been able to 
satisfy myself that there is any new formation of connective-tissue 
filaments in the nodular and infiltrated forms of these tumors, nor have 
I been able to find any osseous new formation; but there is no doubt 
that such a new formation occurs in the papillary and villous forms, 
of which we shall hereafter speak. From this description you see 
that Waldeyer's expression about the epithelial formation in carcinoma 
being atypical (tissu heteroadmique of Robin) is also well suited for 
distinguishing carcinomata from adenomata, as typical new formations. 

As regards the vessels in these tumors, we may satisfy ourselves, 
by artificial injections, that the dilatation and new formation, by tor- 
tuosity and looping, are considerable ; only the connective-tissue por- 
tions of the tumor are vascularized, the epithelial portions remain free ; 
this is a very important anatomical criterion, as is the fact that true 
epithelial cancer-cells never unite together as the large epithelio- 
cells of some sarcomata do ; Waldeyer has justly attached great im- 
portance to this latter point. I cannot go any further into the gen- 
eral histological description of these tumors, and hope that they may 
be recognizable from the above, although I acknowledge that it is 
sometimes very difficult to distinguish carcinoma from adeno-sarcoma 
and alveolar sarcoma. 38 

According to my whole histogenetic view, I must regard it as im- 
possible for an epithelial cancer to occur primarily in a bone or lym- 
phatic gland. The observations that I know, to this effect (in the 
lower jaw, on the anterior surface of the tibia, in the lymphatic glands 
of the neck), do not seem to me sufficient proof, because the skin and 
mucous membrane are so near ; there may have been an insignificant 
carcinomatous disease of the skin or mucous membrane as a starting- 
point of the disease, without its having been noticed. 

The appearance of the cut surface of this tumor, and its consist- 
ence, vary so, that no general description can be given of it. 

In the great majority of cases, carcinoma appears in the form of 
nodules ; also as indurations of otherwise soft tissues, or as papillary 
proliferations. Rarely, the diseased parts are separated from the 
healthy tissue by a connective-tissue capsule ; but, in most cases, the 
passage from healthy to diseased tissue is more gradual. In some 
cases there is no cancerous tumor, but a cancerous infiltration, there 
being no enlargement, possibly even a diminution in size of the 
affected organ. It is also characteristic of carcinoma that part of the 
new formation is very short-lived, disintegrates directly or after pre- 
cedent fatty degeneration, is reabsorbed, and then the infiltrated 



CARCINOMATA. 685 

fibrous tissue contracts to a firm cicatrix. Besides this cicatricial 
shrinking, and not unfrequently along with it, there is often softening ; 
it is, perhaps, even more frequent than contraction ; at all events, it is 
more extensive. This softening is mostly preceded by fatty degen- 
eration of the cells and caseous metamorphosis ; central softening, 
opening outwardly, formation of a putrid ulcer, with fungous edges, is 
very characteristic of carcinoma. Mucous metamorphosis of the cell- 
protoplasm also takes place in some glandular carcinomata, relatively 
most often in those of the liver, stomach, and rectum ; in rare cases, 
this also affects the connective-tissue stroma. This mucous cancer is 
also called gelatinous or colloid. When cancerous degenerations oc- 
cur on the surface, the papillary layer may develop so as to become 
very prominent, as in some papillary cancers (destructive papillomata) 
of the mucous membrane of the lips, stomach, and portio vaginalis, 
and as in villous cancer, which develops on the mucous membrane of 
the bladder, in the form of dendritic, branched, large papilla?. If the 
cicatricial contraction predominate in a carcinoma (as it does in some 
forms of cancer of the breast), hard tumors or ulcers are developed, 
which have for ages been called scirrhus. Some carcinomata are 
brown or black, but still melano-carcinomata are rare. Most soft 
melanomata are sarcomata. 39 You will more readily acquire an idea 
of the different forms of cancer by studying attentively their origin 
and the localities where they chiefly occur. 

1. Skin (cutis) and mucous membranes with pavement-epithelium, 
Common epithelial carcinoma (specially so called because it was the 
first, and, until lately, the only form in which the main body of the 
cancerous tumor was known to consist of epithelium), or cancroid 
(cancer-like tumors ; this name was chosen because these cancers of the 
skin were considered less malignant than those forms observed in the 
breast, which were considered as the type of true cancer). The cutis 
is covered by a layer of epithelium, from which in the foetus there are 
various ingrowths into the subjacent tissue, namely, the hair-follicles, 
hair, sebaceous, and sweat glands. Mucous glands are formed on mu- 
cous membranes in the same way. Many assert that all these tissues 
may have epithelial outgrowths. I shall not deny^this, but epithelial 
ingrowths may be most readily proved in the rete Malpighii. Next 
to this, a considerable collection of epithelium in the sebaceous glands 
and glands of the oral mucous membrane, and their enlargement, are 
also frequently witnessed ; less frequently, the hair-follicles and sweat- 
glands are implicated. During this ingrowing, the young cells of the 
rete at first preserve their size and form ; even their relation to the 
connective tissue of the cutis remains the same, for those cells lying 



686 



TUMORS. 



Fio. 152. 




Commencing epithelial cancer of the vermilion border of the lip.— Growth of the rete Malpip-hii 
into the tissue of the lip.— Horny epidermis.— The blood-vessels injected. Magnified 60 
diameters. 



Fig. 153. 




Flat epithelial cancer of the cheeks.— Glandular ingrowth of the rete Malpighii into the con- 
nective tissue, infiltrated with email cells. Magnified 400 diameters. 



CARCINOMATA. 



687 



next to the connective tissue preserve a cylindrical form, just as on 
the normal papilhe of the cutis. 

It is very probable that the epithelial, gland-like ingrowths not un- 
frequently grow into the spaces between the connective-tissue bun- 



Pio. 154. 




Elements of an epithelial carcinoma of the lip. — (Fresh preparation, with addition of very dilute 
acetic acid.) a, single cells with endogenous division of nuclei; 6, a cancroid rod with 
concentric irlobules and outer cylindrical epithelium ; c, an epithelial pearl that has been 
crushed. Magnified 400 diameters. 

dies where lymph circulates, for there the tissue offers least resistance. 
IToster thinks he has proved that all these tubes and cylinders lie 
solely in the lymphatic vessels. Although all his evidence in favor 
cf this view is not tenable, it is still very enticing, for we might then 
readily understand why the adjacent lymphatic glands were occasion- 
ally infected early. 



638 



TUMORS. 



Subsequently, changes take place in these epithelial tubes ; groupr 
of cells unite and form globules, which gradually grow by the deposit 
of new cells of the form of flat epithelium, and thus form the cabbage- 
like, compound epidermis-globules (globules epidermiques, cancroid 
globules, epithelial pearls), which so much excited the astonishment 
of the first person that examined them. 

It is most probable that these globules are developed from a num- 
ber of conglomerated cells, increasing by division, and the peripheral 
layers of cells being flattened by pressure against the parts around, 
which are not very distensible ; hence the larger these pearls become 
the more they project from the cell-cylinders, and hence they often 
appear at the terminal points of the glandular acini. Among the 
cells in the pearls, as in the epithelial parts of these tumors else- 
where, we often meet cells with many nuclei ; also large cell-bodies, 
which have enclosed daughter and grandchild-cells. In some of these 
carcinomata stachel and riff cells have been found in great numbers, 
as in the boundary layers between the mucous and horny layers of 
the epidermis. If the epithelial masses have grown deep into the 
tissue, and if we make a section in these deeper layers of a hardened 
tumor of this variety, we find about the following picture, in which 
the alveoli, filled with epithelium, may readily be distinguished from 
the connective tissue which has become faveolate : 

Fig. 155. 




Prom an epithelial cancer of the hand, the blood-vessels incompletely injected. 

diameters. 



Magnified 



CARCINOHATA. 



689 



The vessels in this connective-tissue stroma assume about the 
shape in Fig. 156, a, while Fig. 156, #, shows a proliferation of vessels 



Fig. 156. 




Vessels from a carcinoma of the penis. Magnified 60 diameters. «, from the developed tu- 
mor tissue, vascular net-work around the epidermis pearls ; S, vascular loops from the sur- 
face of the indurated but not yet ulcerated glans penis. 

in the enlarged papillae of a glans penis, as it occurred just at the 
development of the first epithelial proliferations. 

While in the last-mentioned case, as often happens, the papillary 
hypertrophy appeared at the very commencement of the development 
of the tumor as an essentially characteristic part, in other cases it is 
of an entirely secondary nature, i. e., the epithelial rods on the sur- 
face of the skin or mucous membrane soften, fall out, and leave the 
vascular connective-tissue portion in the form of a pouched ulcer, 
from which different papillary tufts protrude or subsequently grow. 
Carcinoma of the skin may begin as indurated papilloma, or as a wart, 
but just as often it begins as a nodule when the proliferation is at first 
circumscribed, grows into the skin ; it enlarges slowly, without grow- 
ing by apposition of new, small carcinoma nodules. The carcinoma- 
tous proliferation may also enter and grow through the cutis from 
a gradually-increasing surface, without causing any great promi- 
nence. 

There is a decided difference between cancers of the skin, accord- 
ing as the epithelial proliferation enters the cutis more or less deeply ; 
some cases remain quite superficial, scarcely entering the subcuta- 
neous cellular tissue, and growing very slowly (flat epithelial cancer, 
Thiersch) ; others grow rapidly and enter the tissue deeply, destroy- 
ing it (infiltrated epithelial cancer, Thiersch). The above description 
44 



690 TUMORS. 

of cancer of the skin is from the infiltrated form ; in flat epithelial 
cancer the outgrowing cell-cylinders rarely grow deeper than the 
deep layers of the cutis, and consist chiefly of the small, round cells 
of the rete. Along with these proliferations the sebaceous glands 
become larger, fill up with developed large-celled epithelium, and the 
connective tissue is richly infiltrated with small-celled elements. In 
these new formations the development of epidermis pearls is rela- 
tively rare. As viewed on the patient in this commencing stage, the 
whole forms a hard, slightly-elevated infiltration of the cutis, covered 
with desquamating epidermis. This epithelial proliferation is not, 
however, very solid ; occasionally there are disintegration, softening, 
and detachment of the glandular proliferations and sebaceous glands. 
The highly-vascular connective tissue remains, and may continue to 
grow as granulations, or it may partially cicatrize. While this goes 
on in the centre of the new formation, the latter continues to grow, it 
may be very slowly, in the periphery. 

At their very commencement, the cut surfaces of epithelial cancer 
are pale red and hard ; in a short time they appear white and granu- 
lar ; occasionally we may see the large epithelial pearls and rods with 
the naked eye. Ulceration takes place from without .inward, even 
more frequently than by medullary softening from within outward, 
and usually quickly follows their development. Mucous softening is 
rare in these forms. 

In regard to the topography, we may mention the following regions 
of the body as the most frequent seats : (a.) Head and neck y here 
these tumors develop chiefly on the eyelids, conjunctiva, skin of the 
nose and face, the lower lip, oral mucous membrane, gums, cheeks, 
tongue, larynx, oesophagus, ear, and scalp. The first appearance va- 
ries greatly : the worst cases begin as nodules in the substance of the 
mucous membrane or skin, and quickly ulcerate from central soften- 
ing ; other cases begin on the surface ; a fissure, crack, indurated ex- 
coriation, epidermoid scab, or a soft wart, forms ; this at first apparently 
insignificant affection may remain superficial for a long time, slowly 
extending laterally, less so in depth, and having indurated borders. 
If the carcinoma develop from a wart-like formation, it may perma- 
nently preserve the papillary character. The parts once diseased are 
forever destroyed by the metamorphosis into cancerous tissue; in 
typical epithelial carcinomata there is no cicatricial shrinking; the 
ulcers which rapidly develop from these new formations vary, like 
other cancerous ulcers ; sometimes smaller or larger shreds of tissue 
from the depths of the ulcer become gangrenous, leaving a crater-like 
loss of substance ; sometimes the new formation proliferates, forming 
an ulcer with fungous, overgrowing edges. Not unfrequently, a 



CARCINOMATA. C91 

cheesy pulp may be squeezed from this ulcerated surface ; it comes 
out in a worm-like shape, just as the inspissated sebaceous matter 
does from the glands of the skin (comedones or maggot) ; this pulp 
is a mixture of softened epithelial masses and fat. Sooner or later, 
there is a gradually-increasing swelling of the neighboring lymphatic 
glands of the neck, which is not unfrequently painful ; by degrees 
the glandular tumors unite together, or with the primary tumor ; new 
points break out, and the local destruction gradually progresses ; the 
new formation also extends in depth, destroying the bones of the face 
or skull, and taking their place. Death may result from suffocation or 
hunger, due to pressure of the tumor on the air-passages or oesopha- 
gus, or from pressure on the brain after perforation of the skull; 
more frequently, after gradually-increasing marasmus, it results from 
complete exhaustion, with the signs of excessive cachexia. On au- 
topsy,- we hardly ever find metastatic tumors in internal organs. 
All of these carcinomata on the head, face, and neck, are much more 
frequent in men than in women. The average duration of life of 
patients with cancer of the tongue and oral mucous membrane is a 
year to a year and a half. Cancers of the lips are radically curable 
by early and complete extirpation. 

In previous works, I have termed the above form of flat carcinoma 
of the skin, " cicatrizing, atrophying, epithelial cancer, or scirrhous 
cutis," to define it more accurately from ordinary epithelial cancer. 
But now it seems to me better to make no special subdivision of it, 
hence I at once state that this is the mildest form of cancer of the skin, 
and, with few exceptions, attacks old persons ; the disease occasion- 
ally begins as an infiltration of the papillary layer, with small nodules, 
always superficial ; usually there is at first a local collection of yellow- 
ish epidermis, a small scab, after whose removal the skin appears at 
first only slightly reddened, scarcely infiltrated ; when detached, the 
crust forms again ; after repeated detachments, we find under it a small, 
rough, fine papillary, dry, ulcerated surface, which occasionally has, 
even at this period, hard, slightly-elevated edges ; the small ulcer, on 
which new, dry crusts constantly form, extends through the cutis, but 
rarely into the subcutaneous tissue ; its tendency is rather to spread 
laterally, occasionally it even heals in the centre, forming a cicatrix and 
new healtlry epidermis, while a moderate induration and ulceration 
slowly progress in the periphery. In some cases there is no ulcera- 
tion, only infiltration of the skin, with epidermis-scales and subse- 
quent cicatricial shrinking. 

The most frequent seat of fiat epithelial cancer is the face, es- 
pecially the cheeks, brow, nose, and eyelids ; still other parts of the 
skin, which are subject to any form of epithelial carcinoma, may be 



692 TUMORS. 

attacked by this form ; it is most frequent between the fiftieth and 
sixtieth year, and I find it as often in women as in men. Often the 
whole cutaneous surface, and especially that of the face and hands, 
appears very dry, and is covered by numerous dry, flat, yellow epider- 
mis-crusts, as well as by numbers of small infiltrations, which often 
disappear again. This cancerous infiltration extends very slowly; 
occasionally it is six or eight years before a portion of skin as large as 
a dollar, or a side of the nose, or an eyelid, or portion of the ear, is 
destroyed ; it rarely proceeds more rapidly. As the patients are gen- 
erally old, they occasionally die of other diseases, and, for the same 
reason, there is often no recurrence after operation. But, even in cases 
not operated on or treated in any way, this form of carcinoma appears 
infectious in but few cases ; the infection never extends beyond in- 
filtration of the lymphatic glands, which does not occur till late, and 
then goes on just as slowly as the primary infection. Some writers 
have wished to banish this form of cutaneous cancer from the lists of 
carcinomata, and to place it among chronic inflammations as ulcus 
rodens (Hutchinson) , or as a form of lupus peculiar to old persons. 
The various combinations of this neoplasia with distinctly-marked 
cancer in some points of the infiltrated edges, the possibility of its 
changing to proliferating cancer of the skin, and some other anatomi- 
cal and clinical peculiarities, render it certain, in my opinion, that this 
form of infiltration and ulceration belongs among the cancers, and is 
the mildest and most feebly infectious among them. 

(b.) The second part of the body where this form of carcinoma is 
frequent is about the genitals. The portio vaginalis uteri, vagina, 
labia minora, and the clitoris, the penis, especially the glans and pre- 
puce, are the parts most frequently affected. Of all these parts, the 
portio vaginalis uteri is especially liable to the disease, and here car- 
cinoma ulcerates rapidly, and, as the surface of the tumor becomes 
deeply fissured and assumes the appearance of a cauliflower, this is 
often called cauliflower cancer, but, as sarcomatous papillomata may 
produce the same forms, this designation is uncertain. On all of 
the above localities the ulcerated tumor may have a destructive ul- 
cerating or a fungous character, it may also be either infiltrated 
or superficial. The separation of uterine cancer is accompanied by very 
badly-smelling sanies, and often with repeated parenchymatous 
haemorrhages. As regards the subsequent course of the disease, the 
retroperitoneal lymphatic glands are affected sooner or later ; death 
usually results from marasmus; in these cases, also, we very rarely 
find metastasis in the internal organs, except in the neighboring 
glands which are directly infected. 

(c.) Of other parts of the body that require the attention of the 



CARCINOMATA. 



693 



Burgeon, we have to mention the hand, and especially the back of the 
hand. Not long since, I saw an epithelial carcinoma on the right 
forearm, which had developed from a fontanel, kept up for ten years 
with peas. I also saw an ulcer of the foot, wmich, after lasting for 
years, without any known cause became cancerous. 

(d.) We also mention here the carcinomata growing from the 
vesical mucous membrane, which also has a pavement epithelium. 
Inaccessible as it is for surgical treatment, the surgeon must still be 
well acquainted with it, to enable him to make a differential diagnosis. 
It has already been frequently mentioned that papillary proliferations 
occur in carcinoma ; this is particularly often the case in cancers on 
the inner surface of the bladder, which frequently grow in the shape 
of branched villi, and have consequently received the special name 
of " villous cancer." 

Cancers starting from the cutaneous epithelium and glands have 
the same relation to villous cancer that adenoma has to papilloma. 
When papilloma assumes a peculiarly luxuriant growth, and at the 
same time epithelial masses grow into the part of skin affected, soft- 
ening the connective tissue or muscle, in short, when the tumor as- 
sumes a distinctly destructive character, it may be regarded as car- 
cinomatous papilloma or villous cancer. The boundaries between 

Fig. 157. 




Papillary formation of a villous cancer of the bladder, after Lamhl. a, without, 6, with epi 
thelium ; c, isolated epithelial cells of the villi. Magnified 3r>0 diameters. 



694 TUMORS. 

simple papilloma and villous cancer may be just as difficult to define 
as those between adenoma and carcinoma. 

As above stated, a tumor like a mushroom forms on the inner sur- 
face of the bladder, growing into its cavity, and floating in the urine. 
its base being attached to the wall of the bladder, like a carcinoma, 
and its long, branched villi being covered with very large epithelial 
cells, while the ground-work of the papillae is composed of connective 
tissue, whose meshes contain epithelial cell-cylinders, such as occur 
in carcinoma (Fig. 157). 



Now, a few words about the course of the above carcinomata as a 
class. They" usually appear in elderly persons, say from the fortieth 
to sixtieth year, rarely later, but, unfortunately, it is not so rare for 
them to come earlier ; I have seen cancer of the tongue in a boy of 
eighteen, and cancer of the uterus in a woman of twenty years. On 
the whole, country people are more subject to cancer of the lip than 
city people are. The earlier these carcinomata appear, the more pro- 
liferant the local tumor, the earlier the lymphatic glands are implicated, 
and the more rapid the whole course. It has often been observed 
that, after entire removal of the tumor, there is no recurrence. In 
some cases the disease runs its course very quickly, in a year ; in oth- 
ers it lasts three, five, ten years, or longer (flat cancer of the skin) ; 
sometimes, also, the recurrence is only in the lymphatic glands, as 
when a cancer of the lip has been completely extirpated, but at the 
time of operation cancer-germs were already present in the cervical 
lymphatic glands. The new formation in the gland at first appears 
pale red, is a rather hard, diffuse infiltration, or a white kernel, but 
with time it becomes softer, and, to some extent, pulpy and purulent. 
The cervical lymphatic glands infiltrated with cancer have a great 
tendency to ulcerate ; their microscopical structure is the same as that 
of primary cancer. I think there is no doubt that secondary cancer 
in the lymphatic glands is always due to transplantation of cancer- 
germs from the original focus (see page 607). The above forms of 
cancer scarcely ever go beyond the lymphatic glands ; infection of in- 
ternal organs (liver, lungs, spleen, kidneys) is very rare. The con- 
stancy with which carcinoma occurs at certain points, especially where 
mucous membrane passes into skin (vagina, penis, lips), has justly 
always excited much attention. It was natural to seek the causes of 
the disease in the structure of these parts, and in the irritations to 
which these openings were subjected ; the dislike that most modern 
pathologists have to specific, unknown irritations has induced them to 
seek different causes for explaining the obscurity about the specific 



CARCINOMATA. 695 

causes of tumors of these parts. In regard to the lips in old persons, 
Thiersch attaches great importance to the fact that there, as in the 
cutis elsewhere, considerable changes take place with advancing age : 
there is decided atrophy of the connective and muscular tissues, so 
that the epidermis-formations, hair-follicles, sebaceous and perspira- 
tory glands, as well as those of the lip, attain the preponderance, and 
receive most of the nourishment ; hence all irritations affecting the 
lips (bad shaving, smoking tobacco, wind, bad weather, etc.) chiefly 
attack the glandular parts of the lip, and induce hyperplasia. In 
England, epithelial cancer often attacks the scrotum of chimney- 
sweeps (chimney-sweeper's cancer), from the irritation of the soot, it 
is supposed. These things may certainly have some effect, but it re- 
mains unexplained why they should be followed by cancers or infec- 
tious tumors, and not by chronic inflammations, catarrhs, etc. I shall 
not here follow this discussion further, but merely refer you to what 
was said about the etiology in the introduction to the section on 
tumors. 

2. Mammary glands, I place cancer of the mamma here, as this 
gland is also a derivative of the epidermis, a cutaneous fat-gland on a 
large scale. The mammary cancers, however, differ greatly from those 
already described, and, although true epidermis-cancers occur in the 
breast, starting particularly from the areola, they are very rare. 

Mammary cancer, which is unfortunately very frequent, seems to 
me almost always to begin with a coincident enlargement of the small, 
round, epithelial cells in the acini, and with small-celled infiltration 
of the connective tissue around them. With our present methods of 
examination it is impossible to tell whether the first changes occur 
in the gland-cells, or in the connective tissue ; for the grouping of 
small, round cells about the acini soon becomes so excessive, that it 
constantly becomes more difficult to make out the further fate of the 
glandular acini. From my tolerably numerous observations on this 
subject, made by aid of the most improved methods, I think I may de- 
scribe the following as the subsequent course : 

The collection of cells in the acini leads first to their enlargement, 
which is occasionally accompanied by a trace of secretion (as is shown 
by the escape of serum from the nipple). As the collection of cells 
continues, there is more enlargement of the acini, and in such different 
ways, that we may distinguish an acinous (often large-celled) and a 
tubular (chiefly small-celled) form of mammary cancer. The former 
leads to the development of large, lobulated, glandular nodules ; hence 
I call this the " acinous form," since in it the rough outlines of the 
acini are preserved. The following picture is a slightly-magnified one 
of the borders of such a tumor : 



696 



TUMORS. 



Fig. 158. 




Mammary cancer, acinous form. Magnified 50 diameters. 



The groups of epithelial cells, which are enlarged and grown to 
thick glandular clubs, are enclosed by infiltrated connective tissue, 
and traversed by a fine net-work of connective tissue (stroma), which 
I regard as the remains of the former partitions between the acini, 
but which others consider as mostly new formation. 



Fig. m. 




Soft mammary cancer; alveolar tissue of the carcinoma; alcoholic preparation. Magnified 

100 diameters. 



CAECINOMATA. 



697 



If we make a section through a hardened preparation of an aci- 
nous, soft, mammary cancer, when magnified more strongly, the tissue 
appears as above. I consider the cells in the large connective-tissue 
meshes as of epithelial origin (Fig. 159). 

This variety of mammary cancer is mostly soft, granular on section, 
grayish white (medullary). If we scrape the cut surface of such a 
cancerous tumor, we readily evacuate a thick, whitish pulp; if we ex- 
amine this while fresh, we find nodular cells, very pale, composed of 
large, many-formed cells with large nuclei ; many of these cells contain 
several nuclei ; they may perhaps be segregating. 

The connective-tissue frame-work in which these elements were 
embedded, when empty, looks about as follows, if strongly mag- 
nified : 

The second form, which is more frequent (is harder, and on section 
pale red), may be termed the " tubular " form, as the acini do not 
maintain their form, but grow into the connective tissue as very thin 
cell-cylinders, while it becomes infiltrated with cells. As in this form 
of cancer the cells from the epithelium do not usually grow so large 
as in the preceding form, and as the cells collected in the connective 

Fio. 160. 




Prom a mammary cancer. Magnified 300 diameters, a, cells with several nuclei (fresh prepa- 
ration, with some water added); &, glandular cell- cylinders (fresh preparation). 

tissue occasionally lie tegether in groups, it is evident that it must be 
very difficult to decide which of these cancers come from the cell- 
masses of glandular epithelium, and which are pure derivatives of 
connective tissue, former wandering cells. 



698 




Connective-tissue frame-work of a cancer of the breast ; the thick striae are plentifully infil- 
trated with young cells. Brushed-out alcohol preparation. Magnified 100 diameters. 



Hence all observers are not yet convinced that these frequent 
forms of mammary carcinomata are true cancer, as some of them 



Fig. 162. 




Cancer of the breast ; tubular form. Magnified 150 diameters. 



CARCINOMATA. 699 

regard all the cells occurring here as derived from connective tissue. 
The final decision in this matter can only be made by the history of 
development; as long as we have no means of always distinguishing 
the young derivatives of epithelial cells from wandering white blood- 
cells, and the derivatives of connective tissue, we shall scarcely be 
able to say from every preparation whether this form of cancer of the 
mamma is more of an epithelial or connective-tissue nature. 

Although all forms of cancer of the breast have a tendency to 
ulcerate, this is more the case in the softer than in the harder forms. 
The hardness of cancer of the mamma does not always depend on its 
richness in cells, but even acinous cancers that are rich in cells may 
be hard, if the cells are enclosed in tense connective-tissue capsules, 
as the normal acini are. The softening is central in nodules lying 
near the skin, or in the harder forms it is more frequently from with- 
out inward at points where the tumor presses against the skin and 
has become united to it. Mucous softening occurs rarely, mucous 
metamorphosis of the gland-cells is probably never seen. To the 
naked eye the softened spots appear whitish-yellow, granular (cas- 
eous, fatty softening) or grayish or dark red from vascularity, espe- 
cially if there have been extravasations. By softening and encap- 
sulation of the softened spot, which may be deeply seated, cysts may 
be formed in these carcinomata ; retention and secretion cysts may 
also be developed in the mamma along with or in the cancerous 
tumor. 

Fig. 163. 




lb 



Cancer of the mamma, from a cicatricially-atrophied part. Magnified 200 diameters. 

Atrophy is a very frequent process in cancer of the mamma ; the 
nipple or other parts are thus retracted like the navel. On micro- 
Bcopic examination of these atrophied parts we see connective-tissue 
striae with atrophied connective-tissue corpuscles, and the section of 
fine, branched canals (atrophied alveoli) which are filled with cell 



700 



TUMORS. 



detritus or fat. This atrophy of the new formation is in some cancers 
of the mamma such an important factor, that it has given rise to a 
special form of cancer, " atrophying, cicatrizing cancer." It cannot be 
denied that in its pure form this variety of cancer has certain pecu- 
liarities which distinguish it from the ordinary, most frequent forms 
of cancer of the mamma ; hence w T e prefer to describe it separately 
hereafter. 

The development of cancer of the mamma is accompanied by con- 
siderable distention of vessels and new formation. In the youngest 
parts of the new formation there are numerous fine vessels and net- 
works of vessels ; in the older, especially in the softening parts, the 
vessels grow wider, then are thrombosed and destroyed, so that, about 
points of softening in tumors, similar net-works of dilated vessels 
form as are developed on the formation of abscesses. 

The following are the clinical symptoms of the development and 
course of ordinary cancer of the mamma. The disease usually begins 
between the thirtieth and sixtieth year, rarely earlier or later; the 



Fib. 164. 




Vascular net-work from a very young cancerous nodule of the mamma. Magnified 50 diameters. 

women attacked are usually otherwise perfectly healthy ; married and 
unmarried women, fruitful and barren wives, of all conditions, are at- 
tacked. Not unfrequently the parents or grand-parents have died of 
carcinoma. Most frequently in one breast, especially in the outer and 
lower part, there forms a tumor, at first small and painless, that some- 
times remains unnoticed for months ; it is hard, firmly seated in the 



CARCINOMATA. Y 01 

Fig. 165. 




Vascular net-work around points of softening in a cancer of the breast. Magnified 50 diameters 



gland, but at first movable under the skin and over the pectoral mus- 
cles ; at first its growth is moderately rapid ; possibly a year passes 
before the tumor reaches the size of a small apple ; its volume is not 
always the same, occasionally it is larger and more sensitive, especially 
before and during the menses ; but occasionally the tumor collapses 
somewhat, and is perfectly indolent. These symptoms are partly 
dependent on congestion of the mammary gland, partly on atrophy 
and cicatrization going on in the tumor itself. With time, in the 
course of some months, the tumor grow T s larger ; the skin over it be- 
comes immovable, and below it adheres to the pectoral muscle. The 
patients frequently do not notice the commencement of the swelling 
of the axillary glands, and, if the surgeon's attention be not occasion- 
ally directed to this region, the enlargement of these glands, which 
appears as a hard swelling of these parts, is not discovered till late ; 
sometimes also these glands lie so deep and so high under the pectoral 
muscle that they are not felt till they have grown quite large. The 
lymphatic glands of the neck are less frequently affected in cancer of 
the breast ; w T hen they are, the prognosis is more unfavorable. If the 
progress of the tumor goes on undisturbed, the course, when moder- 
ately rapid, is as follows : The tumor of the mammary gland and 
those of the axillary glands gradually unite, so as to form a nodular, 
wavy, immovable swelling, which at some points adheres to the skin ; 
the pressure of the tumor on the nerves and vessels in the axilla 
causes neuralgic pains and oedema in the arm ; the patients, who pre- 
viously had felt perfectly well, are compelled to keep in bed by the 
pain and swelling of the arm, which come on more especially at night, 
and have a piercing, boring character, while previously they may have 



702 TUMORS, 

been able to attend to their household duties. In this stage (say two 
years after the commencement of the first tumor) another symptom 
has usually appeared, or does so shortly, namely, "ulceration. This 
generally begins with the following symptoms : Part of the tumor be- 
comes prominent, the skin grows thinner and redder, is traversed by 
visible vessels ; finally a fissure or vesicle forms on the elevated, red, 
fluctuating tumor ; now part of the cancerous tissue which is exposed 
to the air becomes gangrenous, breaks into shreds, and a crater-like, 
excavated ulcer is left, which long maintains this shape, if the sur- 
roundings and base of the ulcer be still hard ; but, if the parts about 
the ulcer be already soft, the substance of the tumor begins to prolif- 
erate at the edges and from the depths, and to cover the parts around 
like a fungus. An ulcer, sometimes torpid, sometimes fungous, is 
thus developed ; its secretion is always sero-sanious ; badly-smelling, 
gangrenous shreds are often thrown off. But, what is still worse, 
parenchymatous or even arterial haemorrhages occasionally occur from 
the surface of the ulcer, and exhaust the patient. We have followed 
the condition of the patient till he has become partly or entirely bed- 
ridden ; we now soon come to the catastrophe : the patient becomes 
pale and greatly emaciated ; the appetite is lost, the strength grows 
less, the nights are often sleepless from the pain ; opiates must be 
resorted to, to give the patients sleep and temporary relief. We now 
have the well-marked picture of cancerous dyscrasia or cachexia. It 
may go on in this way for months ; the smell from the cancerous ulcer 
infests the chamber, the patients become weaker, the skin grows 
grayish-yellow and clayey. Pains on breathing and in the region of 
the liver, as well as in the bones of the limbs, come on. The patient 
becomes marasmic, and dies in agony after protracted, painful suffer- 
ing, unless the end is hastened by pleurisy or peritonitis. On au- 
topsy, in most cases we find carcinomatous tumors of the pleura, 
liver, and occasionally of the bones, it may be of the femur or of the 
vertebras, or else of the ribs on the side where the tumor of the 
breast was. The whole disease has lasted two years and a half. 

For many cases of cancer of the breast the above description will 
be very accurate, but there are some modifications of this course. 
First, the rapidity of the local course varies ; the tumor may remain 
confined to the breast, without any affection of the lymphatic glands 
— a very rare case. The disease of the glands appears almost simul- 
taneously with the tumor of the breast ; this always leads us to ex- 
pect a very rapid course of the disease, while conversely a very late 
and moderate local spread to the lymphatic glands indicates a mild, 
slow course of the whole disease. Carcinomata may come in the two 
breasts simultaneously, or in one soon after the other ; this makes the 



CARCINOMATA. 703 

prognosis much worse. In some cases there is no isolated tumor of 
the breast, but the whole gland, with the skin, becomes diseased at the 
same time. Lastly, an adenoma or an adeno-sarcoma may have ex- 
isted eight or ten years, and then rapidly assume the character of a 
cancer, i. e., become immovable, painful, and accompanied by harden- 
ing of the lymphatic glands. Cases also occur where the tumor of 
the mamma diminishes so much that it is supposed it has entirely dis- 
appeared ; unfortunately, this does not prevent the general outbreak 
of the disease, although it appears to retard it, or only to occur in 
mild cases, such as run on from four to six years. Some patients die 
early of anaemia from the ulceration and haemorrhage, without any 
metastatic tumors having formed. The period for the occurrence of 
metastatic cancerous tumors in the internal organs also varies ; gener- 
ally, when the local growth of the tumor is slow, metastatic tumors 
appear late ; still, there are exceptions to this rule. In cancer of the 
breast the localization of the secondary tumors is very regular, as 
already stated • the pleura, liver, and bones, are the most frequent seats 
of metastatic tumors. 

The varying course of cancer of the breast renders it ver} r diffi- 
cult, indeed almost impossible, to compare the result of early or late 
operations with those cases that run their course without operation ; 
even the age of the patient causes great differences : in old persons, 
the disease almost always runs a slower course than in young ones ; 
numerous entirely unknown influences come in play. The most ex- 
perienced surgeons have given very different opinions about operating, 
some declaring that the course of the disease is hastened by operation, 
others that it is retarded. The statistical tables that have been pub- 
lished aid little in solving this question, because cases of all sorts are 
thrown together in them ; to obtain a correct result from them, the 
cases must first be separated on certain principles. But what good 
would this do ? It would always be a question, in each case, whether 
we should aid the patient by an operation or not. The tumors will 
almost always return in the cicatrix, in its vicinity or in the neighbor- 
ing lymphatic glands, because they are usually operated on too late ; 
the patients will then die of metastatic tumors, if they are not carried 
off sooner by suppuration, haemorrhage, or acute disease. How much 
does the patient suffer from the tumor? What danger does it induce 
locally ? These are the first urgent questions. But I am anticipating 
by considering here the treatment, which we propose studying more 
attentively at the end of this section on cancerous diseases. Exami- 
nation of the enlarged lymphatic glands, which partly adhere together, 
shows that the smaller are more succulent and vascular than normal : 



704 TUMORS. 

the larger contain hard white or grayish-white nodules, and are occa- 
sionally softened, caseous, and have a granular cut surface. On the 
whole, the lymphatic glands show the same characters as primary can- 
cers ; this also extends to the microscopic texture. Although it could 
probably only be proved in pigmented carcinoma that the first swell- 
ing of the lymphatic glands depends on transformation of tumor-cells 
into the lymphatic glands, still I consider the same thing true of all 
carcinomata; in some cases the. epithelial nature of the new forma- 
tion in the lymphatic glands is just as striking as in the primary tumor 
of the breast, in others such a distinction is impossible. 

Carcinomatous nodules of the pleura, which develop after car- 
cinoma of the breast from direct conduction of the seeds, are usually 
hard, pure white, and small-celled; the same is true of the external 
appearances of secondary cancer of the lungs and liver ; but the latter 
are not unfrequently large-celled and acinous. Although I regard it 
as probable that these carcinomata are also due to direct emigration 
of carcinoma-cells or to transportation of the latter by the lymphatic 
or blood vessels, this cannot be proved. 



Some cases deviate from the above course, as is shown by early 
and continued shrinking of the new formation. This form is called 
scirrhus mammce, atrophying, cicatrizing, shrinking carcinoma, con- 
nective-tissue cancer. The picture of the disease and the anatomical 
changes will appear from what follows. 

In the mammary gland, rarely before the fiftieth year, there forms 
a hard spot — we cannot say a swelling — but the hardening is rather 
accompanied by a partial or even a total decrease in size of the gland; 
this hardening usually forms without, rarely with severe pain ; it comes 
on very slowly. If we now suppose the hardened glands removed 
and examine the diseased portion, we find the tissue so hard that 
we can scarcely cut it ; to the naked eye, the cut surface shows a hard, 
fibrous cicatrix, with connective-tissue striae gradually extending into 
the comparatively healthy parts around. In typical cases, except this 
cicatrix, we shall scarcely discover any thing pathological with the 
naked eye ; but, at the periphery of some of these tumors we see a 
pale-reddish part with a fatty lustre, more marked in spots, lying be- 
tween the cicatrix and the healthy tissue, and passing into both. If 
we examine fine sections of the cicatricial tissue after previously 
hardening it still more in alcohol, we find little besides connective 
tissue and elastic filaments ; but the connective-tissue strias have not 
the same peculiar regular course that they have in fibroma ; they are 
irregularly intertwined, and, as above stated, they are accompanied 



CARCINOMATA. 



705 



by many elastic filaments, which rarely happens in fibroma. But 
examination of the bordering tissue gives the following : There is 
cell-infiltration, to a very slight extent, it is true ; there is development 
of small groups of pale bodies, like lymph-cells, with single nuclei, as 
in the commencement of any new formation. Part of these cells are 
arranged in long groups (tubular), somewhat larger than the rest; 
these are doubtless derivatives from the epithelial remains of the 
shrunken glandular acini. All the cells of the neoplasm appear to be 
very short-lived, for they are scarcely formed before they commence 
to decay, without going on to further development ; then the con- 
nective tissue, which has been somewhat distended, shrinks together, 
and, as a result of this process, we have the cicatrix; but peripherally 
this slight cell-infiltration constantly extends ; hence complete, spon- 
taneous disappearance of the new formation very rarely, if ever, occurs. 
If the borders of this tumor be inspected under a low power of the 
microscope, we see how the small-celled infiltration advances between 
the meshes of the connective tissue, and closely follows them. 

Fia. 166. 




Connective-tissue infiltration advancing into the cntis from the borders of a cancerous nodule 
of the mamma; the dark shadings correspond to the advancing small-celled infiltration. 
Magnified 50 diameters. 



The extension of this infiltration into the fatty tissue occurs just 
as in inflammation ; most of the 3 r oung cells are found in the vicinity 
of the vessels, so that we can scarcely avoid thinking that in these 
cases also white blood-cells escaping from the vessels cause the cellu- 
lar infiltration. 

As in these cases the infiltration of the connective tissue with 
45 



706 TUMORS. 

lymphoid cells is very decidedly the predominant morbid process, 
while the epithelial proliferation is very secondary, I formerly tried to 
give this form of cancer of the breast the name of " connective-tissue 
cancer." But, as this has led to misinterpretation in regard to the 
modern anatomical understanding of carcinoma, I shall not try to 
preserve this term. 

Fig. 167. 




Cellular infiltration of the fatty tissue in the periphery of a hard cancer of the breast ; the blood- 
vessels injected. Magnified 200 diameters. 

The peculiar anatomical and clinical course has caused some sur- 
geons to strike this new formation from the list of tumors, and par- 
ticularly from that of cancers. If we examine more closely the clinical 
course of these cases, we have already noticed that they usually only 
occur in old persons, and that the local disease progresses slowly ; 
some cases last seven or eight years before half of one breast is atro- 
phied. The general health meantime remains unimpaired. The 
lymphatic glands occasionally participate in the disease ; in this case 
the process goes on just as in the mamma ; there is very little enlarge- 
ment, but much hardening and cicatricial shrinking. The more rap- 
idly and completely the new formation atrophies, and the more slowly 
the process extends, the more injurious it is ; after extirpation or 
cauterization this variety of cancer does not recur for a long time, if it 
does so at all; metastatic tumors are rare; in the main, the infiltra- 
tion does not appear to differ much, anatomically, from that in chronic 
hepatitis and nephritis with subsequent shrinking ; why, then, distin- 
guish this scirrhus from those processes ? Wernher terms this disease 
of the mamma cirrhosis mammae. I recognize perfectly the justice 
of doubting the carcinomatous nature of some cases of scirrhous mam- 



CARCINOMATA. 707 

mas, but must still insist upon classing them generally among cancers, 
for the following reasons : As you already know, among tumors the 
process of contracting is peculiar to cancers ; moreover, the contract- 
ing cancer is not unfrequently combined with ordinary cancer; indeed, 
it is more common for more or less cancerous proliferation to go on 
along with the scirrhous affection, while the wholly-cicatrizing cancers 
are relatively rare. This combination, which occurs neither in cirrho- 
sis of the liver nor of the kidney, speaks entirely for the near relation 
of this cicatrizing new formation to cancer ; in these combined cases 
there are also local recurrences of the extirpated tumors, tumors of 
the lymphatic glands, and even metastatic cancers of internal organs. 
In the tumors that consist chiefly of cicatricial substance, and hence 
are to be classed rather with scirrhus than with ordinary cancer, we 
may give a tolerable prognosis, inasmuch as the disease always runs 
a slow course. 



We now mention another form of cancer of the breast which also 
begins as an induration in the gland, but soon extends to the skin, 
and there, in the form of small nodules, quickly spreads over the 
whole skin of the anterior wall of the thorax ; the second breast is 
often affected the same way. This cancer lenticitlaris (Schuh), squirrhe 
pustuleux ou dissemine ( Velpeau), apjDears partly as a primary, partly 
as a recurring form after extirpation of hard cancer of the breast, and 
not exactly in old women. This small nodular (we might almost say 
tuberculated) form may, by confluence and contraction, lead to actual 
lacing in of the skin of the thorax from the front and sides (cancer en 
cuirasse, Velpeau) ; the course is slow, the tendency to metastases 
to internal organs is not great, but the prognosis is very bad, because 
every attempt to prevent local extension by operation is in vain. 



3. Mucous membranes with cylindrical epithelium. Most cancers 
that form in the nose and antrum Highmori, and gradually extend to 
the upper jaw, ethmoid and sphenoid bone, as well as into the orbit, 
start from the mucous membranes of the nose and antrum Highmori. 
The ciliated or non-ciliated epithelium of these membranes only ex- 
tends to the openings of the mucous glands, and even in the develop- 
ment of cancers of the glands at these points rarely grows into the 
deeper parts. It appears to be rather the acini of the gland itself 
from which the proliferation proceeds, for these cancers appear to be 
mostly composed of acini or tubuli, which have small or larger round 
cells, rarely cylinder-cells, still more rarely ciliated cells. The shape of 
the newly-formed acini and their size here differ enormously, but often 



V08 



TUMORS. 



are so distinct, so normal, that they may be mistaken for normal mu- 
cous glands ; to render this deception complete, it not unfrequently 
happens that the newly-formed acini secrete mucus, which remains 
and collects in them. If the secretion from many acini be retained, 



Fig. 168. 




Cancer of the mucous glands from the interior of the nose. Magnified 200 diameters. 



the form of the neoplastic glandular acini be perfectly round, and the 
interstitial connective tissue be but slightly developed, the hardened, 
fine sections of such a tumor may very much resemble tissue of the 
thyroid gland. The interstitial tissue is usually very soft in these 
tumors; as in the corresponding mucous membranes themselves, it 
may be almost mucous. Interstitial papillary proliferations of hyaline 
vascular connective tissue (cylindroma) also occasionally occur here. 

These tumors are always very soft, white, medullary, or gelatinous, 
except when very vascular ; then they are dark red. The bones are 
destroyed by caries, without a trace of reactive bony new formation 
or osteophytes. The appearance and clinical course of these tumors 
are somewhat peculiar, differing from other carcinomata. They occur 
any time after the twentieth year, grow rapidly, and project sometimes 
through the nares, again through the cheeks or inner can thus of the 
eye ; they are occasionally very sharply bounded or encapsulated, 
which may be known by palpation, and proved on operation ; some* 



CARCINOMATA. 



709 



times tliey are more diffusely spread in the upper jaw. In these mu- 
cous-gland cancers of the face I have never seen infection of the lym- 
phatic glands, and am convinced that these patients could be saved by 
an early complete operation. In all the patients that I .have operated on, 
I have never been satisfied that the tumor was entirely removed by the 
operation ; it always projected too far posteriorly or upward to per- 
mit the operation to be completed with safety. Hence, I usually wit' 
nessed local recurrences, which proved fatal by marasmus or pressure 
on the brain, or else the patient died from the extent of the operation ; 
in none of the cases examined post mortem did I find internal tumors. 
In the stomach gland-cancers are frequent, especially with mucous 
softening (gelatinous cancer), and secondary cancer of the liver ; can- 
cer of the duodenum is very rare ; of the parts of the intestinal canal 
attacked by this disease we are only interested in the cancers of the 
rectum. These are almost exclusively gland-cancers, and the prolifer- 
ation proceeds from the large glands of the large intestine, which 
grow in the shape of tortuous and branched tubes ; the calibre of the 
gland is often maintained, and they fill with mucus, and the cylinder- 
cells may maintain their form and become very large. The intersti- 

Fig. 169. 




Adenoid cancer of the rectum. Magnified 200 diameters. 



tial connective tissue is strewn with small, round cells, sometimes 
softened, and often very vascular. Usually at first the muscular coat 
of the intestine is hypertrophied ; subsequently it also is affected by 
».he ulceration, which generally begins earlv. 



110 TUMORS. 

As the first symptoms of cancer of the rectum are usually consti- 
pation, discharge of mucus, and slight haemorrhage, these patients 
are mostly treated for some time as if suffering from haemorrhoids, be- 
fore the diagnosis is made by digital examination. Induration and 
nodular infiltration, leaf-like proliferations commencing close above the 
sphincter ani, soon extend to the whole circumference of the mucous 
membrane, so that a thick, prominent ring, a stricture of variable 
length, may be felt. This new formation can only be removed by ex- 
tirpating the rectum. When the rectum is taken out, we generally 
find an ulcer with elevated edges and indurated base, and the parts 
around infiltrated with medullary substance; at some points also 
there are cicatricial contractions. The inguinal and retroperitoneal 
glands are affected rarely and late in the disease. The patients gen- 
erally die from the stricture of the intestine, from marasmus, due to 
haemorrhages, and putrefaction of the cancerous tissue. 

Occasionally also cancers, composed mostly of cylindrical epithe- 
lium, start from the pars cervicalis uteri. These first attack the 
uterus, then the surrounding parts, and lastly infect and infiltrate the 
retroperitoneal glands ; they combine with flat epithelial cancers, and 
do not differ from these in their course. 

4. Lachrymal^ salivary, and prostatic glands. The same kind of 
tumors grow from the lachrymal glands that we have already de- 
scribed as growing from the nasal mucous membrane, acinous glan- 
dular new formations, with soft, occasionally mucous, or even papillary 
hyaline interstitial connective tissue (cylindroma). They develop 
about the age of puberty, and are characterized by great tendency 
to local recurrence. All the cases of this nature that I have known 
of finally died from the local recurrence; it might be not for sev- 
eral years ; neither the lymphatic glands nor internal organs were 
affected. 0. Becker has described tumors of this sort, in which most 
of the glandular acini contained a certain quantity of mucous secre- 
tion, as also occurs more especially in the glandular cancer of the 
rectum. 

The salivary glands may also be the seat of glandular cancer, but 
they do not come till old age ; then, however, they grow rapidly, and 
not unfrequentfy resemble chronic inflammation. The newly-formed 
acini are often more tubular than acinous ; epithelial pearls occur on 
the ends of the tubuli, covered with cylinder-cells. These patients 
usually succumb to the ulceration of the tumor and the general ma- 
rasmus ; internal carcinoma is a rare sequent. 

In the prostatic gland I have seen glandular cancer a few times ; 
it was very soft, and in one case where partly extirpated it was very 
vascular, and of acinous structure. From the excellent statistical 



CARCINOMATA. 711 

work on malignant new formations in the prostate by 0. Wyss, it ap- 
pears that, in almost every case, these carcinomata also prove fatal 
solely from the local symptoms. Lymphatic glands and adjacent 
parts become infected ; there are very rarely secondary cancers of in- 
ternal organs. 

5. Thyroid gland and ovary. I place these two organs together, 
as they both originate from true glandular epithelium, and both con- 
tain follicles, formed by choking off of glandular canaliculi. In can- 
cerous disease both organs fall back into the embryonal type, i. e., the 
follicles grow again to tubes and canaliculi, from which again new 
follicles are developed; but some of these carcinomata, which are 
rare, consist entirely of cell-canaliculi, without any development of 
follicles. Young persons, as well as old ones, may be attacked by 
this form of cancer. Its course is usually rapid, for the cancers of 
the thyroid grow into the windpipe or close it by pressure, while the 
ovarian tumors are characterized by their enormous growth and rapid 
adhesions with the surrounding parts, and by the speedy development 
of ascites prove dangerous. 

From variations in their course and anatomical structure we must 
separate the different forms of carcinoma ; we may consider their 
treatment together. Treatment of the carcinomatous dyscrasia (car- 
cinosis) is usually regarded as a partie honteuse of medicine. I can- 
not admit this. It is true we cannot cure the disease ; but is not this 
also true of many other acute and chronic diseases ? Can we arrest 
a cold in the head at any stage ? Can we check the course of the 
acute exanthema or typhus ? Can we cure tuberculosis ? Certainly 
not ; in all these cases, as in many others, the disease runs its typical 
course ; we give little medicine, at least we avoid all heroic reme- 
dies. In carcinosis our therapeutic impotence only appears so great 
because the disease almost always proves fatal, and we can do nothing 
to oppose its course; in fact, our treatment is as inefficacious in 
coryza as in carcinosis ; but the former is not a fatal disease, hence no 
special demand is made on the physician. We have become accus- 
tomed to failing to cure cold in the head ; we must grow accustomed 
to the course of cancerous as to that of some other diseases ; this 
will not interfere with our sympathy for these poor patients, nor must 
it prevent our striving for increased knowledge and improved treat- 
ment of the disease. I think that much may yet be attained in this 
direction. 

The indications for treatment are to remove the cancerous tumor 
as soon as possible, so as to avoid infection, or at least obstruct its 
course, and thus diminish the evils accompanying it. 



712 TUMORS 

As long as cancer has been known, remedies for it have been 
sought ; there is no active medicine, no form of dietetics, or mineral 
springs, that have not been recommended for cancer, and, to some ex- 
tent, actually believed in. I should have to root up the entire old 
and new materia medica if I would tell you of every thing that has 
been thought and written on this subject. Like all incurable dis- 
eases, carcinosis also has been a wrestling-place for the charlatan, and 
even of late years Italians and Americans have claimed to cure the 
disease by special nostrums. Unfortunately, all these are deceptions, 
or at least what part of it is true has been long known. 

Unfortunately, the etiology of cancer gives no clew to treatment ; 
we know too little of the causes why certain tumors are so infectious, 
while others are not so. A blow, kick, etc., may occasionally induce 
an outbreak of the disease in some few cases, but cannot excite the 
predisposition to cancer. In some cases inheritance of the disease is 
evident. Care and anxiety may hasten the course of the disease, but 
do not induce it. All this is of no avail for the treatment. There is 
no specific for carcinosis ; but by this we do not mean to say that 
all internal treatment is unnecessary or useless. By no means. The 
disease should be treated internally whenever there are indications 
for treatment, or any symptoms pointing to the use of certain reme- 
dies. As anaemia is not unfrequent in cancerous patients, iron in va- 
rious preparations, or chalybeate mineral waters, may be employed. 
Occasionally, in persons with faulty nutrition, cod-liver oil, etc., as 
well as bitter medicines, prove beneficial by aiding digestion. Very 
debilitating treatment, by sweating, purging, mercurials, etc., is to 
be avoided, for life will be preserved the longer the more the strength 
is maintained. Among the mineral springs, the active ones, such as 
Aix-la-Chapelle, Wiesbaden, Karlsbad, Kreuznach, and Rheme, are 
injurious ; only the milder indifferent thermal springs, such as Ems, 
Gastein, Wildbad ; also, milk and whey cures, strengthening moun- 
tain air may be recommended without injury, if their use seems on 
other accounts desirable. Residence in southern climates is usually 
of little benefit for cancerous patients. Toward the end of life, when 
debility is increasing, a strengthening, easily-digested diet is impor- 
tant ; and lastly, as the pain increases, the skilful use of various nar- 
cotics relieves the sufferings and death of the patient. The disease 
of internal organs may offer special indications to which I shall not 
here refer. So much about internal treatment, which I only follow 
when not quite sure of the diagnosis, or when I do not consider the 
case suited for operation. 

As regards external treatment, the first thing alwaj^s is the re- 
moval of the tumor, if this is admissible, from its locality. The opera- 



CARCINOMATA. 713 

tion may be done with the knife or caustics ; the ligature or 6craseur 
can scarcely ever be employed here (the latter, perhaps, answers only 
in amputating the penis or tongue). But, before passing to the choice 
of either of these methods, we must consider the question, whether it 
is advisable to operate at all, even if it can be done easily and without 
danger to life, for the views of experienced surgeons differ on this 
point. Some surgeons never operate for cancer. They assert that 
the operation is always in vain, because the disease recurs ; if the re- 
curring tumors be operated on, new recurrence takes place the sooner ; 
these surgeons even assert that, the more we operate locally, the 
sooner secondary lymphatic tumors and metastatic cancers form, the 
local tumor acting as a sort of derivative for the tumor-disease ; that 
this product of disease cannot be removed without favoring the out- 
break of the disease elsewhere ; that, if we nevertheless wish to re- 
move the tumor, we should lead the morbid juices to some other point, 
as by establishing an artificial ulcer by means of a fontanel or seton. 
Concerning this view, which comes from the old humoral pathology, 
we may say that it remains unproved, and is partly also disproved by 
experience. We consider it as demonstrable by daily experience that 
the glandular swellings are essentially due to the development of the 
primary tumors ; we have already stated our belief that the participa- 
tion of the lymphatic glands in carcinoma is, according to all analogy, 
caused by local contagion, let the process be what it may. When 
cases occur where, after removal of cancers of the breast or lip, swell- 
ings of the lymphatic glands appear, though previously imperceptible, 
we must consider that the commencement of the disease was so slight 
as to escape observation. — How far the existence of a primary and 
secondary cancer of the lymphatic glands influences the subsequent 
course of the disease, the appearance of metastatic tumors and general 
cachexia, is a question which cannot be answered, because the disease 
does not run its course in a regular time ; if it did, we might form a 
rule as to the advisability of operating, by comparing cases that were 
operated on with those that were not. Approximate results might 
be attained by classing together cases that were alike in age, consti- 
tution, variety of the tumor, etc. ; but, as the accurate distinction of 
the varieties of carcinomata, and consequently an exact arrangement 
of the cases, has only lately been attained, and even now is not gener- 
ally known, we cannot at present expect much in this direction ; in- 
dividual observations rarely suffice for definite conclusions. The ex- 
perience from carcinoma of the face, that the most extensive disease 
of the lymphatic glands is very rarely accompanied by metastatic 
tumors, strongly favors the belief that the disease is not made more 
active by these strongly-developed local tumors, and that carcinomata 



114: TUMORS. 

of the lymphatic glands do not increase the predisposition to metasta- 
tic tumors. — In reply to the question, whether carcinoma should ever 
be operated on, we may say that operation probably has no direct in- 
fluence on the diathesis, and that the operation, if done at all, must 
be done for other reasons. We said intentionally that the operation 
has no direct influence on the course of the disease, but we think it 
has an indirect influence, as the tumor induces other causes of disease ; 
the weakness, anaemia, and disturbance of nutrition caused by the sup- 
puration and pain from a cancerous tumor, perhaps also the constantly 
gnawing care with the ever-recurring reflection on the incurable nature 
of their disease, are factors which may well hasten the course of the 
malady. Under some circumstances I consider it the duty of the 
physician to deceive the patient about the incurability of this disease, 
whether he considers an operation as possible or not; where the 
physician cannot aid the patient, he should alleviate his sufferings, 
mental as well as physical. Few persons have the quiet of mind, res- 
ignation, firmness, or whatever you choose to call it, to enjoy what 
remains of life, if they know they have an incurable disease. Although 
perhaps externally quiet, patients will thank you little for confirming 
what they may have feared. On this point you will have many trials, 
and I must leave you in each case to do whatever is dictated by your 
personal shrewdness, knowledge of men, and your feelings. — Although 
we may not get rid of the diathesis by the operation, as when, having 
removed a diseased portion of breast, we fail to prevent new nodules 
forming in the remaining portion which was previously healthy, or in 
the other healthy breast (regional recurrence), soon after the cicatrix 
has healed, still by the early removal of the primary tumor we may 
prevent the neighboring glands, or the adjacent portion of mamma, from 
becoming diseased. Few as are the complete recoveries from cancer 
of the breast after operation, I believe they will grow more frequent 
when the family-doctor, to whom they are generally first shown, urges 
operation earlier, for at present they usually let the best time for 
operation slip by, and the women do not consult professed surgeons, 
till the local disease and the affection of the axillary glands are so far 
advanced that a complete operation is no longer practicable. The 
favorable results from early extirpation of true cancer of the lip should 
embolden us to remove other cancerous tumors early. If it has hither- 
to rarely been possible to operate on cancers early and completely, 
there are still important local causes which indicate even late opera- 
tions, to prevent as long as possible the advance of the tumor to parts 
where the disease would necessarily destroy life. Although in most 
cases there will be local recurrence, this will not take place for months, 
perhaps for a year , meantime, life will not be directlv endangered ; 



CARCINOMATA. 715 

occasionally also it is a question of saving from entire destruction cer- 
tain parts of the face, as the lips, eyelids, or nose, which may subse- 
quently be replaced by a plastic operation. It would be very unjust 
to consider such operations useless, because they cannot cure the dis- 
ease, for they render the patient's life easier and more agreable — if 
only for a time, still, possibly, for the greater part of the time that he 
yet has to live. We might be very glad, if, by an operation or other 
treatment, we could temporarily restore to the pleasures of life a 
patient with advanced tuberculosis of the lungs, as is the case in oper- 
ating for some cancerous tumors. In short, there are many cases 
where we do good by the operation ; very often I should consider it 
wrong to refuse to operate. — We see other cases, however, where it 
is more difficult to decide. In slowly-progressing cancers of the breast, 
as in connective-tissue cancers, I consider an operation, which is free 
from danger, as admissible, but not necessary. If an eyelid be de- 
stroyed, or the nose partly or entirely lost, an operation is advisable, 
in the first case to protect the eyeball, in the second to remove the 
deformity, and the rather so, because in these slowly-progressing flat 
cancers of the face frequently there is no local recurrence ; in such 
cases only one thing would prevent my operating, viz., great debility 
or advanced age of the patient ; at least then extensive plastic opera- 
tions are no longer advisable ; even the unavoidable loss of blood, and 
keeping the patient in bed after the operation, may suffice to extin- 
guish the feeble vital spark. Then comes the question about the ad- 
missibility of the operation, where the tumor is in a dangerous loca- 
tion, when an operation is necessary that may end fatally, or at least 
is just as likely to end fatally as to result in cure. Here we have to 
drop general reflections, and consider the individual cases ; the danger 
seen in an operation varies greatly with the experience of the surgeon, 
and the individuality of the patient ; one principle we should adhere 
to : only to operate when after careful examination we can hope to 
remove all of the diseased part ; a half-operation, leaving behind por- 
tions of the tumor, should never be done. We should be careful to 
operate only in healthy tissue, if possible a centimetre or more from 
the perceptible infiltration, for in this way alone can we be certain 
of removing all of the diseased part. Occasionally in desperate cases 
we may prolong life by a bold operation, even if the cancerous tumor 
be already very large, but generally in such operations we shall see 
more patients die than will recover. 

We have now to criticise the caustics chiefly used in cancers. In 
the course of time opinions about caustics have differed greatly ; at 
times they were greatly preferred to the knife, again they were en- 
tirely thrown aside. The views of most surgeons of the present day, 



716 TUMORS. 

as well as my own, incline to the latter view. I decidedly prefer the 
operation with the knife or scissors, because I then know exactly what 
I remove and I can judge more certainly if all the diseased part has 
been excised. Hence, I regard the operative removal of cancer as 
well as of other tumors to be preferable as a rule. But where there 
is a rule there are exceptions. In very old, anaemic, or timid patients, 
caustics may be employed, and, if the treatment be continued till all 
the diseased portion is destroyed, the result will be favorable. Physio- 
logically caustics would have some advantages ; for it is supposable 
that the cauterizing fluid may enter the finest lymphatic vessels, and 
thus more certainly destroy the local disease. But this does not oc- 
cur readily, because the tissue with which the caustic comes in contact 
instantly combines with it, and its further flow is thus prevented. 
Formerly it was asserted that recurrence did not take place so 
soon after the use of caustic as after operation with the knife, but 
this has not been confirmed ; hence I only maintain the above ex- 
ceptions. 

For a caustic I prefer chloride of zinc to all others for destroying 
cancers ; you may use it as paste or as caustic arrows. If it is a sur- 
face you wish to cauterize, to equal parts of powdered chloride of 
zinc and flour you add enough water to make a paste, which you apply 
to the surface. If you desire to cauterize more deeply, you mix one 
part of chloride of zinc with three parts of flour or gum and some 
water, and let them form a cake and dry ; this may readily be cut up 
into small pointed cylinders half a centimetre or more in thickness ; 
with a lancet you make an opening in the tumor and press the caus- 
tic arrow into it ; you repeat this operation till the tumor is perforated 
with arrows at about three quarters of an inch distance from each 
other. In four or five hours this cauterization is followed by moderate, 
often by very severe pain, which you may greatly modify by giving 
a subcutaneous injection of morphine directly after the cauterization ; 
the next day you find the tumor changed to a white slough. This 
becomes detached after five or six days, earlier in soft tumors, later in 
hard ones. If the cauterization has extended far enough into the 
healthy parts, after the detachment of the eschar there is left a good 
granulating wound, which soon cicatrizes ; if the carcinomatous mass 
again grows, the paste or arrows should be again applied, etc. 

These cauterizations are occasionally very painful and uncertain 
as regards the extension of the caustic, but they occasionally are 
advantageous. Other celebrated caustics are Vienna paste, arsenic 
paste, butter of antimony, chloride of gold, etc. ; iodide of potash, 
chromic acid, concentrated solutions of chloride of zinc, fuming nitric 
acid, sulphuric acid, etc., are less employed. 



CARCINOMATA. 717 

Now a few words of advice about the local treatment of cancer- 
ous ulcers which are not, or at least are no longer, suited for opera- 
tion. In some of these cases the proliferation of the cancerous mass 
from the wound is enormous, and it often annoys and debilitates the 
patient ; here we may make partial cauterizations or employ the hot 
iron ; by the palliative destruction of the proliferating mass, we occa- 
sionally attain tolerably good results. The chief indication for treat- 
ment in these patients is suppuration of the ulcer, which is occasionally 
horridly fetid, and sometimes the pain. For preventing the disagree- 
able secretion, the hot iron is a good remedy ; the smell may be les- 
sened by compresses wet with chlorine-water or purified acetic acid, 
creosote, carbolic acid, permanganate of potash, sprinkling with pow- 
dered charcoal. The latter readily absorbs gases, as you know from 
chemistry, and is here an excellent remedy ; unfortunately, it dirties 
the wound, so that we abstain from its frequent use. For the pain of 
carcinomatous ulcers, narcotics have been applied locally, as by sprink- 
ling on powdered opium ; but, when injected subcutaneously or given 
internally, the narcotics act more certainly ; hence at last we always 
resort to morphine for these poor patients. I particularly enjoin on 
you patience in caring for and alleviating the sufferings of these unfor- 
tunates ; it is indeed sad for the physician to be able to do so little 
good in these cases, but still you must not abandon them. 



JBBIEF EEMAEKS ABOUT THE CLINICAL DIAGNOSIS OF TUMOES. 

I cannot take it amiss if you are at first somewhat confused by 
what I have said to you about tumors ; if it will encourage you, I may 
acknowledge that formerly it was the same with me when I was in 
your present position. Only long study and practice in the differen- 
tial diagnosis of tumors, for which there is opportunity in the clinic, 
render it possible to attain any certainty on this difficult point. The 
consistence of the tumor and its appearance, its relation to the parts 
around, its locality, the rapidity of its growth, and the age of the pa- 
tient, are the points from which we start in judging ; sometimes one, 
sometimes another, of these points gives the decision. Let us take an 
example : A man about fifty years old comes to you, ruddy and strong 
for his age ; for many years he has had a tumor on the back, which 
formerly gave him no trouble ; it has only been inconvenient since it 
has reached nearly the size of a child's head. The tumor is elastic, soft 
but not tense or fluctuating, movable under the skin ; the latter is un- 
changed ; there has never been pain in the tumor, nor is any caused 
by the examination. In this case the diagnosis is very easy : from 



VI 8 TUMORS. 

the location, from its seat in the connective tissue, its slow, painless 
growth, etc., it can scarcely be any thing but a lipoma, or possibly a 
soft connective-tissue tumor ; but the former is most probable. Let 
us take another case : A woman with a tumor of the breast comes to 
you ; this tumor is hard, nodular, as large as an apple ; over the sur- 
face the skin is retracted at spots, and is adherent to the tumor. 
From time to time there has been piercing pain, the tumor is sensi- 
tive to pressure, the axillary glands on that side feel hard. The 
woman is forty-five years old, well nourished, and looks healthy. Here 
also the diagnosis is easy; it is a carcinoma: 1. Because the patient 
is at the age when cancerous tumors of the breast are most frequent, 
while adenoma and sarcoma usually occur earlier ; 2. The consistence 
might point to fibroma, but this very rarely occurs in the breast, and 
the swelling of the lymphatic glands speaks against this view, and in 
favor of carcinoma ; 3. Carcinomata are painful, as this case is, while 
sarcomata and fibromata are not so, usually. We might give further 
reasons for the diagnosis, but these will suffice. Let us take a third 
case : A boy ten years old has had for two years a slowly-enlarging, 
moderately painful swelling of the middle part of the lower jaw ; at 
this point the teeth have fallen out without being diseased ; the en- 
largement of the bone is evenly round, and reaches from the first back 
tooth of one side to the similar point on the other ; below, it is hard 
as bone, above (in the mouth) it is covered by mucous membrane, is 
firm and elastic. Can this bony swelling be the result of chronic in- 
flammation, of a caries or necrosis ? This is not probable : 1. Because 
the pain has always been slight ; 2. Because there has been no sup- 
puration, which would scarcely fail to occur in an inflammation of the 
jaw that had lasted two years; 3. Because the swelling is more 
bounded and regular than it is apt to be in bony deposits in caries 
and necrosis ; 4. Because, at the patient's age, osseous inflammation 
in the lower jaw is not apt to occur unless from phosphoreous poison- 
ing, which has not occurred here. Hence this is a case of tumor ; is 
it an osteoma ? The part projecting into the mouth is too soft for 
this ; we may pass a fine needle into the tumor from above. Is it a 
chondroma? Consistence, form, mode of growth, and age of the 
patient, agree with this view, but the locality does not ; chondromata 
in the middle of the lower jaw at this age are very rare. It is a cen- 
tral osteo-sarcoma, probably a giant-celled sarcoma ; all the symptoms 
speak in favor of this idea, and you know that these tumors are fre- 
quent in the lower jaw during youth. I say you know — I might better 
say you will gradually learn ; and I can only advise you, whenever 
you have examined a patient with a tumor at the clinic, to read about 
it when you go home, and to compare the individual case with the 



CLINICAL DIAGNOSIS OF TUMORS. 719 

general characteristics of the tumors that I have given you. When 
you have done this for a time, and in the course on pathological 
histology, under the instruction of your teacher, have examined 
many tumors, you will obtain a better idea of them, and will have all 
their peculiarities painted on your memory. 



CHAPTER XXII. 

AMPUTATIONS, EXARTICULATIONS, AND RESEC- 
TIONS. 



LECTURE LI. 

Importance and Significance of these Operations. — Amputations and Exarticulations. — 
Indications. — Methods. — After-Treatraent.— Prognosis. — Conical Stumps. — Prothe- 
sis. — Historical Eemarks. — Resections of Joints. — History. — Indications. — Methods. 
— After-Treatment. — Prognosis. 

Gentlemest : We have often had occasion to speak of amputa- 
tions and resections ; so, before closing these lectures, I will explain 
to you these important operations, by which we remove limbs or 
portions of limbs which are so diseased that we cannot restore them 
to health. These operations, which are often so beneficial, even to 
saving life, are sometimes regarded as a testimonium paupertatis of 
surgery ; for cutting off diseased parts is not a genuine cure, if by 
cure we mean by our skill to restore to its normal state a part of the 
body which has been changed by disease. However, if you take 
this high standard for every thing in our art, the bounds of medical 
science will become very limited. In the same way, you could say 
a cataract is not curable ; for the cloudy lens is not again made clear, 
but is removed. Many of the most brilliant cures made by derma- 
tologists, where they have used caustics, must be regarded as proofs 
of the impotence of our art ; and the same is true of a case where 
you prevent a man from suffocating by removing a tumor from the 
larynx. In the strict sense of the word, the most brilliant " cures " 
are made in such diseases as syphilis ; by antisyphilitic internal 
treatment, we often cause extensive and old morbid products to dis- 
appear in a few weeks, as if by magic. But such undoubted cures 
are rare in other diseases ; we often have to content ourselves with 
destroying the diseased part, and thus preventing not only the 



RESISTANCE TO AMPUTATION. 721 

spread of the disease to neighboring parts, but also its injurious 
effects on the general system. The smaller and more unimportant 
for the life of the organism the diseased part is, the quicker we shall 
decide upon sacrificing it. The larger the part to be removed, the 
greater not only the danger attending the removal, but the more 
effect will it have on the subsequent usefulness of the patient. This 
brings an unscientific social element among indications for amputa- 
tion, which is frequently very important. Thus, a rich man could 
live, and to a certain extent enjoy life, even after losing all four ex- 
tremities ; for the physiological uses of the limbs may be supplied 
by the labor of other persons, and labor may be bought. But for 
any one dependent on the work of his hands or feet, the loss of a 
limb, or in some artisans the maiming of a finger, may ruin his pros- 
pects in life. How can a postman, bricklayer, or turner get on 
without sound legs, or a jeweler or shoemaker with only one hand ? 
I have often had to remove a finger which had been drawn into the 
hollow of the hand by a cicatrix, because it prevented the patient 
from grasping an axe or spade as his business required him to do. 
How often I have heard patients say : " So you can't cure my foot? 
I would sooner die than lose it ; for what could I do without it? I 
am a ruined man ; I cannot stand it ; you shall never take it off ! " 

But one does not readily die from chronic diseases of the extrem- 
ities ; the pain, continued for weeks, months, or years, finally wears 
out the strongest ; and then love of life, and becoming accustomed 
to the thought of being able to earn a livelihood even after losing a 
limb, finally decides most patients to submit to amputation, though 
sometimes not till it is too late. 

The opposition of severely wounded persons to amputation varies 
greatly ; it depends chiefly on the appearance of the injured part, 
and on the amount of pain. If the extremity be torn to shreds, and 
pieces of crushed bone be seen in it, there will be little opposition to 
amputation ; the same is true when there are excessive pain and great 
ecchymosis, and the fingers and toes are immovable. But if this be 
not the case; if the severity of the injury be only recognized by the 
surgeon — for instance, if it be a wound of a joint with fracture of a 
bone, without much deformity or functional disturbance, if the pa- 
tient can move his toes and fingers and has no pain — it is often dif- 
ficult to explain to him the necessity for an operation ; it requires 
confidence in the surgeon as in a superhuman being to induce him to 
permit amputation. You will often find your surgical notions met 
by insuperable objections. If, after a few days, the dangerous 
changes which you may have foretold occur, and the patient begs to 
be amputated, you may sometimes have to say, " It is too late ; " but 
46 



722 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

will you be so cruel as to say, " I told you so " ? It is a trying mo- 
ment for the surgeon. If there is the slightest prospect of a cure, 
even under such circumstances, he will amputate ; the hope of saving 
under such circumstances a patient who has been "given up " is an 
evidence of youthful and justifiable pride in surgical power. But 
when we fail to succeed time after time, and grow weary of trying- 
for the rare successes, we become more resigned, and watch with re- 
gret the sinking ship without sending out the life-boat of our surgi- 
cal skill. Seductive as may be the hope of accomplishing wonders 
by unusual skill, we must still shun the danger of showing our skill 
to be impotent. For too many mishaps finally annul in every con- 
scientious surgeon the pleasure and trust in his art. 

I hope what has been said will make you think seriously, before 
any important operation, whether you should operate, and how. You 
must remember that in any serious operation you require the patient 
to put his life in your hands, and you owe him your best knowledge 
and skill. 

It is difficult to give general indications for amputations and re- 
sections ; almost any general rule in surgery might be criticised in 
special cases; but it will be well to epitomize what I have said on 
these points during the present lectures, and I will add something 
about the performance of the operations and the after-treatment of 
the patient. 

AMPUTATIONS AND EX ARTICULATIONS. 

In some injuries of the extremities, it is certain from the first 
that the limb must become gangrenous, or that the consequent sup- 
puration will be so great as to seriously endanger the life of the 
patient. But if primary amputation is not submitted to, and gan- 
grene is far advanced, amputation will probably not prevent death ; 
and the same .is true in advanced phlegmonous inflammation with 
septicaemia. The only hope of success is in cases where you can am- 
putate in perfectly healthy tissue ; for instance, when, in traumatic 
gangrene which has spread from an injury of the hand or forearm 
to the elbow-joint, you can amputate high in the arm or at the 
shoulder- joint. Under analogous conditions, similar operations on 
the thigh or hip-joint are much less favorable. 

If conservative treatment has been successfully tried for a time, 
and then symptoms of pyaemia appear, amputation may be resorted 
to with some hope of success in the upper extremities, but rarely so 
in the lower limbs. 

In these so-called secondary amputations, a favorable result is 
more probable when pyaemic symptoms have not appeared, but from 



OCCASIONS FOR AMPUTATION. 723 

excessive inflammation the skin has suppurated so extensively that 
we cannot hope for the wound to close ; or when the patient has 
fallen into a marasmic state from slow suppuration of large joints or 
bones. 

Injuries of the hands or feet may also lead to amputation, when 
of such a nature that, under the most favorable condition, they would 
induce a useless, constantly ulcerating stump. After evulsions or 
crushed wounds especially, the bones may protrude and the stump 
may require a regular amputation. The results of frost-bite must be 
treated in the same way; but in the lower limbs we should not 
delay amputating too long when the line of demarkation has been 
formed ; sloughing off of considerable portions of the body too often 
induces septicaemia, which may be prevented by early amputation in 
cases of gangrene from frost-bite or burns. 

In acute idiopathic inflammations of bones and joints, by early 
diagnosis and treatment, we are constantly learning to preserve 
limbs by making proper openings for the pus, and fixing the limbs in 
good position. Still, cases do occur where the patient can only be 
saved by well-timed amputation ; but the choice of the proper time 
is difficult, as it is a question whether and how long the patient can 
bear the suppuration and fever. 

In regard to so-called spontaneous gangrene, or, as old surgeons 
called it, grangrene from internal causes, we must carefully consider 
each case. If the gangrene be due to arterial embolism, and there 
be general disease, the limb should be amputated as soon as demar- 
kation occurs. In gangrene after typhus and severe exanthemata, 
we may wait till the patient has somewhat recovered. In true senile 
gangrene we rarely amputate. If the gangrene be limited to one 
or a few toes, they may be left to come off spontaneously. If it 
extend to the tarsus, it is rarely limited to that part ; but should it 
be, we loosen the protruding bones, and strive, with the least possi- 
ble injury of the soft parts, to secure enough substance to cover the 
stump. 

The chief chronic diseases which give occasion for amputation 
are the chronic inflammations of bones and joints. Caries of many 
bones of the carpus or tarsus, of the knee-joint in non-tuberculous 
adults, of the hip, shoulder, or elbow joints, rather demand resection 
if any operation is required ; amputation is a secondary question. 

Extensive incurable ulcers and incurable or frequently recurring 
pachydermy of the leg often demand amputation, unless the patient 
is to be condemned to constant pain and to be permanently bed- 
ridden. 

Large aneurisms of the femoral artery, especially if likely to rupt- 



T24 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

ure, if they cannot be cured, would certainly prove fatal if amputa- 
tion were not performed. 

In tumors of the extremities which are firmly adherent to femur, 
humerus, or tibia, and grow in between the soft parts, we must am- 
putate. Tumors merely attached to the ulna, radius, or fibula, and 
not extending into the soft parts, may be successfully removed by 
partial resection, or even by removal of the bone. 

Lastly, amputation may be desirable on account of distortion or 
malformation of the foot preventing a patient from walking. 

Now, regarding the method ', we may operate through the joint, 
or saw through the bones. Both ways have their advantages and 
objections. Amputation through the joint appears to be the most 
natural and simple, and least injurious. The soft parts may even 
unite to the cartilage by first intention, or the cartilage may suppu- 
rate and be thrown off, in which case the healing is by granulations 
growing from the bone. The medullary cavity of the bone is not 
opened, so we escape the possibility of primary infection of the me- 
dulla at the time of or shortly after the operation. 

The objections to this operation are, that portions of the serous 
synovial sac remain and have little tendency to primary adhesions, 
and pus readily collects in them after the wound has united. More- 
over, the soft parts required to cover the large articular surfaces are 
very extensive, so that the wounded surface must be very large. In 
case of the knee or elbow joint, the length of the flap required is 
such that we might perhaps make a high amputation of the leg or 
forearm. The stumps left after exarticulation are unfavorable for 
the application of artificial limbs ; for instance, after exarticulation 
at the knee, the joint of the artificial leg would have to be lower 
than the knee on the sound side. 

In amputations we have the advantage of being able to choose 
where we will remove the limb, although, from certain empirical 
reasons, and for greater convenience in applying artificial limbs, 
certain places are preferred. We generally require less flap to cover 
the stump from an amputation than from an exarticulation. Sawing 
the bone is not a very formidable complication of this operation, 
although in many cases more or less extensive necrosis of the sawed 
surface results. If the medulla in its cavity or in the spongy sub- 
stance be infected by a dirty sponge during the operation, or if the 
soft parts become so adherent that pus forming in the medulla can- 
not escape, severe acute osteomyelitis results, which may Induce 
septicaemia and death. In more favorable cases the osteomyelitis is 
limited, and we have necrosis of the bone in the stump ; after six or 
e : ght weeks the necrosed portion may be removed as a sequestrum ; 



I !■ 



METHOD OF AMPUTATIOX. 725 

a bony envelope has formed around it, which replaces the lost bone. 
When speaking of complicated fractures, we have already stated that 
osteophytes may form at the amputated end of the bone. Osteo- 
myelitis of the stump is difficult to recognize at its onset ; but you 
may assume its presence if on the third or fourth day after the 
operation the patient, who has previously been free from fever, sud- 
denly has a high fever with chills and diarrhoea, while the stump 
shows no signs of inflammation, or perhaps most of it has healed 
by first intention, Hence, as the cause of the fever is not inflamma- 
tion of the soft parts, it must be in the bone, unless there be some ex- 
ceptional complication. At all events, in such cases you should open 
the stump and expose the bone, to evacuate any pus that may have 
formed. Occasionally you may in this way save the patient, but 
usually it is too late; for, from the uncertainty of the symptoms, we 
rarely have the courage to lay open the beautifully-healed wound, 
although it would do no great harm even if we were mistaken in the 
diagnosis. 

In amputations and exarticulations the chief points are : 

1. To do the operation with as little loss of blood as possible. 

2. To arrest the bleeding completely, so that there may be no 
secondary hagmorrhage. 

3. To cover the end of the bone with soft parts, so that they 
may unite easily and completely. 

In regard to the first two points, I have nothing to add to what 
I have already said. Before the operation JEsmarcffs bandage 
should be applied; the amputation may then be done without losing 
a drop of blood. After the operation I twist the small arteries, 
and close the larger ones by acupressure or catgut ligature. After 
exarticulation of the femur or humerus I ligate the femoral and 
axillary arteries, because I have found it such slow work to apply 
the needles securely. 

The end of the bone must be covered with soft parts, which must 
heal over it ; if this does not occur, and the bone projects, the granu- 
lations growing out of it either fail to cicatrize and form an ulcer, or, 
if they do cicatrize, the cicatrix adherent to the bone has so little 
vitality that wearing an artifical limb soon makes it sore. This is 
very unfortunate, as it prevents the patient from using the stump, 
and condemns him to two crutches and pain in the ulcerated stump 
for the rest of his days. Hence the bone must be sawed higher up 
than where the soft parts have been divided. In exarticulations the 
soft parts must always be divided below the end of the bone. In 
accordance with these principles, the soft parts may be divided as 
follows, and properly shaped to cover the stump : 



726 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

1. In the circular operation we make a circular incision around 
the limb, strongly retract the divided soft parts, and saw through 
the bone ; then, letting go the soft parts, they fall over the end of 
the bone. To obtain this end most certainly it is well to proceed as 
follows : First divide the skin entirely around the limb, then dissect 
it up, leaving as much as possible of the cellular tissue with it, and 
leaving the muscular fasciae on the muscles. When the skin has 
been dissected up from two to four centimetres, turn it back like a 
cuff, and let an assistant strongly retract it with the other soft parts ; 
then cut through the muscles down to the bone with a circular 
sweep of the knife, at the line where the skin is turned back ; the 
assistant then retracts all the divided parts as far as possible ; then 
with a third circular incision the deep layer of muscles is divided 
about two centimetres higher than the second cut divided them, the 
periosteum is divided, and the bone sawed through. If now the 
parts be allowed to fall into place, three cut surfaces will appear — 
through the skin, through the muscles, and through the bone, the 
last at the bottom of a funnel-shaped wound. Where the limbs are 
thin, the soft parts should reach about six centimetres below the end 
of the bone ; where the; are muscular, this distance should be two 
or three centimetres more. In amputating the forearm or leg, the 
last incision must divide the interosseous muscles before the bone is 
sawed. 

It will be best for you to make the circular operation as I have 
just described it, and accustom yourself to make smooth incisions, 
and to cut by drawing the knife, not by pressing on it. At the 
same time, I do not mean to say that the circular operation may not 
be well done in other ways. Sometimes the following modifications 
are advisable ; they differ partly in the shaping of the stump, part- 
ly in the mode of operating : 

We may amputate a limb in one plane as if done with an axe or 
guillotine; this may be successfully done on the fingers. In the 
fingers we prefer exarticulation to amputation ; but sometimes 
fingers are thus cut off by machines, such as circular saws, straw- 
cutters, etc., and the question arises wmether the stump will do well 
without surgical interference : it will do so, but this is merely on 
account of the anatomical peculiarities of the fingers, where the skin 
is adherent to the sheaths of the tendons and to the bone, and does 
not retract, while the tendons retract in the sheath. The cicatricial 
contraction is concentric, and draws the skin together to the centre 
of the divided bone, as we might draw a tobacco-pouch. At most 
other places in the limbs the skin is so movable on the fasciae, and 
the muscles on the bone, that after an amputation in one plane the 



METHOD OF AMPUTATION. 727 

muscles would retract from the bone, and even the skin would re- 
tract. After the stump, where the bone projects like the point of a 
cone, granulates, the force of cicatricial contraction will draw the 
skin and muscles forward if the latter have not become so united 
with the bone or skin as to become immovable. As this circular 
amputation in one plane always leaves conical stumps, it is only 
done in the fingers or toes. 

Amputation in two planes is also of limited use. Here the skin 
is divided and turned back, then the muscles and bone are divided 
in the same plane ; this leaves the stump covered by the skin only. 
Where the bone is covered by many muscles, they will retract great- 
ly, carrying the skin back with them, so that the end of the bone 
will lie in about the same plane with the skin-flap ; then, in healing, 
the skin becomes attached to the cone-like section of the muscles, 
and we have another conical stump. This method is only admissi- 
ble at points where the muscles will not naturally retract from the 
bones, or where they and their fascise have become adherent to the 
bones and to each other from long-continued precedent disease. It 
may answer in amputations of the leg just above the malleoli or just 
below the head of the fibula, or at analogous points of the forearm ; 
but the skin-flap must be made long enough to cover the stump 
readily. 

The circular amputation in three planes first described, where 
skin, muscles, and bone are separately divided, may be done in vari- 
ous ways. For your first attempts on the -cadaver, I advise your 
doing it as above described. Instead of the last incision through 
the deep layer of muscles, you may turn back the periosteum two 
centimetres from the level of the first incision through the muscles, 
and then saw the bone ; the effect on the form of the stump remains 
the same, whether the deep part of the funnel is covered by perios- 
teum or muscles. This method may be done somewhat quicker and 
more elegantly if, instead of the three incisions in different planes, 
you divide the skin, and then have the assistant strongly retract the 
parts, while you divide the muscles by thin layers. With some 
practice you will learn to make the funnel just the depth you desire. 
But if your assistant retracts the soft parts too energetically, and 
you divide only thin layers, by the time you get down to the bone 
you will have gone too high, and will have too much flap. If the 
assistant retracts too feebly, or if the soft parts are adherent to the 
bone and do not move freely, while you cut rapidly and deep, you 
get too little covering and have a conical stump. 

Lastly, the funnel has been made by cutting obliquely from with- 
out inward to the bone. But these methods are not practical, and I 
will give no further details. 



728 AMPUTATIONS, EX ARTICULATIONS, AND RESECTIONS. 

The circular cut is the normal method for all amputations; it is 
applicable to any part of a limb, although for exarticulations flaps 
or oval sections are more practical. 

2. Flap Operations. — From the soft parts we make one or two 
flaps with which to cover the sawed bone. If we make one flap, 
with a base half the circumference of the limb at the point of am- 
putation, on the other side we usually make a circular cut in one or 
two planes. In flap-amputations, also, it is desirable before sawing 
the bone to turn back the periosteum about one centimetre, and to 
saw the bone about two centimetres above the base of the flap, so 
that as the muscles retract the end of the bone shall not press too 
much against the inner side of the flap. 

I prefer making the flap so that while the patient lies in bed it 
shall hang over the wound without being held by sutures. The 
lower part of the flap should be of skin, the upper of skin and 
muscles. The best way of doing this is first to form the flap by an 
incision through the skin, then retract the skin and cut down 
through the muscles to the bone, then by two incisions make a cir- 
cular cut on the posterior part of the leg. The length of the flap 
should be about one-third the circumference of the limb at the point 
of amputation, and its breadth about one-half the circumference, or 
rather more. 

The single flap has the advantage that where the cause for am- 
putation, the injury or ulcer, or the line of demarkation in gangrene, 
is irregular in outline, we may amputate lower than when we per- 
form a circular operation, so that the stump may be longer and the 
prognosis better. 

I do not think the operation with two flaps has any advantage 
over the circular method. We may make two lateral flaps, or an 
anterior and posterior one, provided the amount and form of the 
soft parts is analogous to the circular amputation. Occasionally in- 
filtration of the skin prevents its being retracted well or turned 
back ; then we may incise it in the direction of the long axis. This 
would make of the circular an operation with skin-flaps, having* the 
funnel shape within. 

Flaps for covering the stump with skin alone are not good, for 
long flaps of this kind readily become gangrenous at the edge, and, 
there being no muscular layer between the skin and the sawed end 
of the bone, the latter readily causes ulceration and perforation of 
the flap. It is true, this is no great misfortune, as the exposed por- 
tion of bone either necroses and separates, or soon granulates and 
cicatrizes ; but in either case the cicatrix becomes adherent to the 
bone, and the subsequent use of the stump may give rise to tedious 
ulceration. 



METHOD OF AMPUTATION. 729 

The method of forming the flaps by transfixing- the limb with a 
long, pointed knife, and then cutting-, usually results with beginners 
in making a muscular flap, which is occasionally tongue-like, is cov- 
ered with too little skin, and does not well cover the wound. If 
before entering the knife we have the skin strongly retracted, and 
pass the knife flat alongside the bone, we may make good flaps ; but 
it requires more experience and practice than the former methods. 

Flap operations are possible at any part of a limb, but are not 
everywhere advisable. By drainage-tubes we may lead off the secre- 
tions, even in flaps formed from below. If the flaps do not unite by 
first intention, the after-treatment is always tedious; for we have to 
guard against cicatricial contraction rolling them in. 

3. Finally, in a third method, the wound made is between a circle 
and a flap ; it is called the oval amputation. The plane of incision 
of the oval lies obliquely from above down ; the upper part of the 
oval is more pointed, the lower more rounded. After making the in- 
cision through the skin, it is to be drawn back, and the soft parts 
and bone are to be divided, as in the circular operation. For am- 
putations the oval incision is rarely used, as it has no advantage over 
the circular or flap operations. In exarticulations of the fingers and 
toes at the metacarpo- and metatarso-phalangeal articulations, or of 
the big toe or thumb, the oval incision is very useful. In exarticula- 
tions at the shoulder or hip joint, I would only employ this method 
when there was not skin enough to form a flap. 



I have still something to add in regard to preparations, assistants, 
choice of instruments, and after-treatment of amputations. 

While the patient is being anaesthetized, or previously (for it is 
hard to bring some patients under anaesthesia when their attention 
is excited by manipulation of the affected part), we carefully cleanse 
the part with soap and water, especially at the point of operation. 
Then the bandage for preventing haemorrhage is applied, and taken 
off again except the upper band. Now one assistant holds the up- 
per part of the limb, another the lower. In amputations the operator 
stands so that he may assist in retracting the soft parts, and that the 
part to be amputated falls to his right; in exarticulations he should 
stand so that he can himself, w 7 ith his left hand, control the move- 
ments of the limb to be removed. 

For amputations and exarticulations of the toes, we use small 
knives with blades four or five centimetres long; they should not be 
too much curved in front, or the point will not enter the joint readily. 
For exarticulations of the hand and foot, as well as for amputations 



730 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

of the lower half of the forearm and leg, we choose a knife with a 
blade about 15 centimetres long ; for the upper part of the forearm, 
the arm, upper part of the leg, and the lower part of the thigh, the 
blade should be from 15 to 25 centimetres long ; for high amputa- 
tions and exarticulations of the thigh, it should be 25 to 35 centi- 
metres long. If you have two small knives with blades 5 centi- 
metres, and one each of 15, 25, and 35 centimetres, it will be enough. 
In amputating I do not like changing knives, and so prefer having 
the cutting edge somewhat rounded in front, so that the skin may 
be dissected up with tha point of the same knife. Other operators 
prefer doing this with a scalpel, then taking another knife to divide 
the muscles, and still another for the periosteum. For pushing back 
the periosteum, I use a raspatorium, though sometimes this may be 
done by the nail alone. A skilled assistant will with his hands re- 
tract the soft parts sufficiently to give the operater room to cut and 
saw; but pieces of clean linen may be used for this purpose. Some 
operators take pride in amputating even thick limbs with small 
knives, thus pushing the simplicity of instruments to the utmost 
point. These points, while not unessential, depend greatly on habit 
and tradition, and each one maj^ follow his own taste. 

Saws for amputation are usually bow-shaped. The bow should 
not be too high, or it will make the saw unsteady; the handle should 
be broad and lie securely in the hand. The blade should not be 
more than two centimetres broad, and the teeth should be bent out- 
ward, else the saw will catch ; and it will be still more apt to do so 
if the assistant holding the lower part of the limb raise it instead of 
depressing it somewhat. After sawing the bone, I usually cut off 
the sharp edges with bone-nippers. 

When the amputation is completed, the vessels are twisted, com- 
pressed with needles, or ligated ; the instruments required for this 
should be all ready. In one of these ways we first close all the ves- 
sels we can find, then relax the elastic band or tourniquet, doing it 
in such a way that the assistant can renew the compression if the 
bleeding becomes excessive ; then we apply acupressure or ligatures 
to any other arteries we see bleeding. In amputations of the thigh 
or arm we may have venous haemorrhages, as the valves are insuffi- 
cient. The veins may be ligated or compressed by needles ; torsion 
of veins is dangerous. Arterial hemorrhage from the medullary 
cavity of bones is very unpleasant ; it is rarely severe. But either 
poking into the medulla with forceps or firm pressure with a sponge 
is dangerous ; and we should entirely avoid the application of styp- 
tics, especially liq. ferri. I advise letting the bleeding alone till all 
other vessels are cared for; if by that time it has not ceased spon- 



AFTER-TREATMENT OF AMPUTATIONS. 731 

taneously, we may compress the main artery of the limb for a while 
with the finger. During the dressing we should only use new, soft 
sponges. 

We should wait till the bleeding is entirely arrested ; it is even 
desirable to leave the wound exposed to the air for a time. After 
circular or oval amputations, the wound is generally united in a ver- 
tical direction. I apply from two to four sutures in the upper part 
of the wound, leaving the lower part open. I secure . flaps in the 
position they are to occupy by from two to four sutures, previously 
placing a drainage-tube dipped in glycerine in the wound across the 
bone, so that the two ends project from the angles of the wound. 

The stump should be so placed in the bed that the secretion from 
the w^ound will flow into a basin placed beneath without soiling the 
bed. After two days acupressure-needles may be removed, and 
after six or eight days the drainage-tube. In cases running a normal 
course, the stump should not swell nor the patient become feverish. 
After ten to fourteen days the parts which have not healed may be 
covered with disinfected charpie and a bandage applied, so that the 
protecting frame may be removed from over the limb and the patient 
move more freely in bed. 

Should the stump swell, or the patient become feverish, the ad- 
hesions of the wound should be broken up with the finger, and any 
pus that has collected be allowed to escape. If there are neuralgic 
pains or frequent twitchings, subcutaneous injections of morphine 
may be made. 

If arterial secondary hemorrhage occurs within twenty-four hours, 
the artery should be sought for and closed ; if it comes later, in the 
second or third week, when the wound is granulating, it is best first 
to seek the bleeding point and close it firmly ; if this attempt is un- 
successful, and the haemorrhage recurs after prolonged digital com- 
pression, the main artery of the limb should be ligated. 

After amputation, many surgeons prefer closing the wound care- 
fully at once, and applying a bandage to hold the soft parts against 
the bone ; other surgeons fill the wound with charpie dipped iu styp- 
tics, and unite the soft parts over it by a bandage, which is not 
loosened for forty-eight hours. I have not seen good results from 
either plan. Neither the attempt to force healing by first intention 
nor the endeavor to secure profuse suppuration from the first is 
good. Complete union by first intention may occur in the open 
treatment ; and if suppuration occurs, the pus can escape readily 
if adhesion does not take place too soon. The surgeon should learn 
by observation to detect this. 

In Listens method the wound is completely united, but drainage- 



732 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

tubes are inserted and light compressing' dressing applied, which at 
first is to be replaced whenever it becomes saturated with blood and 
serum. Lately I have treated some amputation-stumps by Listens 
method with good results ; most German surgeons employ this 
method exclusively after amputations. 

Treating the stump in the water-bath was attended by so many 
difficulties that it was soon given up. 

When treating of circular amputations made in one plane, we 
spoke of the unfortunate occurrence of conical stumps. They may 
be due to unsuitable incisions through the soft parts or deficiency 
of soft parts ; but these are not the only or even most frequent causes. 
In marasmic patients there is sometimes such an atrophy of the soft 
parts of the stump that they grow thinner and shorter, and sink more 
and more on the bone ; this is particularly the case at the lower end 
of the femur, where few muscles are inserted and none originate. 
Moreover, where the covering was plenty, inflammation and suppura- 
tion of the stump induce subsequent atrophy, which retracts the soft 
parts so much, and so attaches them to the bone, that they cannot be 
brought into place by the cicatricial contraction of the granulating 
wound. This is the most frequent cause of conical stumps. As in- 
flammation cannot always be prevented, the operator is not always 
responsible for conical stumps. One might think this could be 
avoided by providing for plenty of flap to cover the stump ; but an 
excess of flap is also objectionable. If we make long skin-flaps, 
their ends become gangrenous ; the loss of substance thus entailed 
is not the worst of this, but we should try to avoid the decomposi- 
tion thus induced. If we have made too long a funnel of muscles, 
there is another objection; that is, the flap is so heavy that its 
weight presses it strongly against the edge of the bone ; we can to 
some extent prevent this by placing a splint under the stump to 
support it. 

If We see that a conical stump is forming, we may apply adhe- 
sive plaster and weights, as in coxitis, to draw the skin down, or at 
least to aid the concentric contraction of the granulating surface by 
freeing it from the opposition. If the patient . bears this without 
pain in the stump or fever, it may be of benefit; but if these symp- 
toms appear, it must be abandoned. If, as a result of osteomyelitis, 
extensive necrosis of the stump occurs, it is indeed shortened, but 
the osteophytes which have formed prevent too much shrinkage, 
and they do not atrophy for years. My experience does not show 
that the stump becomes less conical by the detachment of the seques- 
trum ; usually an operation is required. I split the mass of granula- 
tions upward into the skin and downward to the bone, then push the 



AFTER-TREATMENT OF AMPUTATIONS. 733 

raspatorium along the bone, separating the periosteum and osteo- 
phytes from the bone so far into the soft parts that they may cover 
the stump of bone which shall be left. In sawing, I use a chain-saw 
whose ends I bring out above while the loop is around the bone. 
In limbs with two bones, this subperiosteal resection or amputation is 
done on both bones. Care must be taken that the secretion from 
the periosteal canal from which the bone is removed has a free 
escape ; it is much inclined to close in front by first intention ; then 
pus may collect deeper in, decompose, and cause osteomyelitis. I 
had such an unfortunate case in the army-hospital at Mannheim, in a 
soldier who was amputated successfully for a severe injury of the 
knee, and finally died in this way. At that time I did not know of 
this danger from subperiosteal resection of an amputation-stump, all 
the previous cases that I had operated on in this way having done 
well. 

Observation of old amputation-stumps shows that they change 
considerably in the course of years : some grow very thin ; the mus- 
cular covering or flaps atrophy from disuse, so that only the skin 
remains. In the course of years most stumps become conical even 
if covered with skin alone. This is the more certain to occur, the 
more poorly nourished and marasmic the patient, and especially in 
those who have been amputated for caries of the joint, and who subse- 
quently have caries of other bones or in the stump, or pulmonary tuber- 
culosis or lardaceous disease. The bones of such stumps atrophy, and 
their cortical layer becomes thin. Short thigh-stumps are about the 
only exception. If these are used much in walking, the muscles 
going from the pelvis to the thigh develop, the skin and cellular 
tissue participate in the good nutrition, and the stumps become 
larger than they were shortly after the operation. From most old 
amputation-stumps being covered only by skin, while the muscles 
have disappeared, some have asserted that it is entirely useless to 
employ muscle for covering the stump ; but we have already shown 
that they would not heal so well. 

In Lecture IX. we treated of neuromata in the amputation- 
stump. 

Regarding the prognosis for amputations, we can only say in 
general terms that they are the more dangerous the nearer they are 
to the trunk. Much depends on the general condition of the patient 
at the time of operation. Amputations for injuries are always less 
successful than those made for chronic diseases; but in each case 
there are many points that we will not lose our time about here. 

Surgeons pay too little attention to the subsequent fate and the 
artificial limbs of those they amputate. You will hear many com- 



•734 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

plaints from these patients. Pains in the stump with each change 
in the weather, excoriations of the cicatrix, pressure of the artificial 
limb at one place or another, and constant repairs of it, are the most 
frequent complaints. Some suffer for years from the sensation of 
still having their limb ; for instance, after amputation of the thigh 
they exclaim : " I have a pain in the little toe ; the big toe is being 
torn ; my foot lies in a bad position," etc. During the first days 
and weeks after amputation these sensations are the rule, and are 
so decided and strong that by covering the stump we may deceive 
patients for weeks about the loss of their limbs ; but I have seen 
patients who had the same sensations after years. 

As regards the substitute for the limb, much depends on the 
patient's position in life and his means, not only for baying a limb, 
but for keeping it in repair and replacing it when worn out. 

Artificial arms and well-imitated hands are articles of adornment 
and luxury. Active movements of the fingers have not been attained, 
but mechanism for grasping has been arranged with springs which 
are opened by the other hand. I will not enter into more detail. 
For the arm or forearm, a workman may have a leather case held in 
place by straps, and having a solid piece of wood at its lower end, 
into which may be fastened hooks, etc. On Sunday he may put on 
a hand carved from wood. It is astonishing what intelligent persons 
can accomplish with such apparatuses. I have a long, beautifully- 
written letter from a man for whom I amputated both hands. He 
was an engineer, and got his hands caught and crushed in a rapidly- 
revolving water-wheel. Subsequently, without hands, he earned his 
living by writing. 

As regards the lower limbs, there are few stumps on which the 
patient can bear the entire weight of the body ; and these are the 
stumps after amputations and exarticulations of the foot, and some- 
times after exarticulations at the knee. In all other cases the pa- 
tients rest on the condyles of the tibia or tuber ischii, which bony 
parts are supported on a firm, cushioned ring, which forms the upper 
end of the shield of the artificial limb, and into which the stump is 
introduced. After amputations of the leg, it is desirable to divide 
the weight of the body on these two points. Another way is for a 
patient whose leg has been amputated to rest the bent knee on a 
wooden leg; this, of course, prevents any motion at the knee-joint. 
In regard to the construction of artificial limbs and wooden legs, I 
will say nothing, except to add that for their use a certain amount 
of skill and intelligence is required, as well as pecuniary means for 
attending to the repairs so often required by any artificial limb. 
Hence, for working-people, as most of our hospital patients are, it 



PROGRESS OF AMPUTATIONS. 735 

is better to have firm wooden legs. Even many from the higher 
classes, who have been amputated, and have worried over artificial 
limbs for years, finally resort to wooden legs. Walking with an ar- 
tificial leg and a wooden one differs so much, that one who has been 
accustomed to the latter for years can only use the former after very 
patient trial. 

Simple as the operations for amputation and exarticulation now 
seem, we must remember that from Hippocrates to the present time 
progress has constantly been made in them. That large portions of 
limbs could be lost without danger to life was first taught by their 
spontaneous detachment by gangrene ; the first amputations were 
made for the purpose of removing such gangrenous limbs, and the 
bone was sawed at the line of demarkation. The indications for 
amputation grew very slowly. What especially retarded the intro- 
duction of this operation was not knowing how to check the haemor- 
rhage with certainty ; styptics and the hot iron answered for the 
leg and forearm, but not elsewhere. Hence the progress of ampu- 
tations depended on that of the methods for arresting haemorrhage. 
The greater amputations were only ventured on after the introduc- 
tion of the ligature and tourniquet. The method of amputating 
limbs by strangulating them with a ligature was first introduced by 
Guy de Chauliac and improved by Ploucquet. Of late this method 
has been tried again by the bcraseur (Chassaignac), the galvano- 
caustic ( Von JBruns), and the elastic ligature (Dittel), but has met 
with little popularity. Later surgeons particularly directed their 
attention to amputating as rapidly as possible, so as to cause the 
least pain, and to dividing the soft parts so as to avoid conical 
stumps. Now that we have anaesthetics, and. can avoid haemor- 
rhage by the elastic bandage, rapidity in amputations and exarticu- 
lations is a matter of small moment. Attention is turned to the 
formation of the stump, and since the beginning of this century to 
attempts to secure healing by first intention, and especially to the 
avoidance of any infection from without or from the secretions of 
the wound, and to escaping pyaemia, the most dangerous enemy of 
amputations. The latter points now chiefly claim our attention, and 
recent proposed changes in the method of operating all have them 
in view. 

The first method which was used in Celsus's time was a circular 
incision with retraction of the skin. This was gradually improved 
on. Loicdham (1679) is usually regarded as the originator of the 
single flap, which method was perfected by Verduin (1696). Hava- 
ton and Vermale are said to have been the first to use two flaps. 



736 AMPUTATIONS, EXARTIOULATIONS, AND RESECTIONS. 

The oval amputation was first made by Scoutetten. You will find 
very accurate accounts of amputations in SprengeVs histories of 
operations, and in JLinharfs excellent work on operations, which I 
cannot too highly recommend. 

RESECTIONS. 

I will now make a few general remarks on resections. As previ- 
ously stated, sawing, chiseling, or gouging out diseased or injured 
pieces of bone from the body of the bones, is called " resection in 
the continuity." Most operations of this nature were mentioned 
when treating of complicated fractures, necrosis, or caries ; as were 
the so-called osteotomies for orthopedic purposes. You will see 
these operations so often in the clinic that I will not describe them 
here; they are mostly simple. The indications for them appear from 
what has been said. 

We have also spoken of " resections of joints." I have already 
told you that these operations, which in civil practice occur espe- 
cially for caries, have different results and indications for each joint. 
The same is true of resections of joints in gunshot-wounds ; each 
joint has its special resection history. Resections, especially resec- 
tions of whole joints, are of much more recent date than amputations. 
The first excision of a carious head of a humerus was made by White, 
1768 ; resection of the elbow- joint by Moreau, 1782 ; of the head 
of the femur by White, 1769; of the knee-joint by Park, 1762. 
But at first these operations were not popular ; they were said to be 
too difficult, tedious, and painful, and it was thought that the final 
results would not be good. It is only within the past thirty years 
that they have been accepted by surgeons, and the methods of their 
performance are still being improved. At first it was merely at- 
tempted to remove the affected portion of bone without loss of 
the limb, so that the parts might heal. Later, attempts were made 
to retain the function of the false joint left after the resection, by 
judicious selection of the lines of incision, method of operating, and 
after-treatment. Surgeons even went so far as to excise stiff joints 
that were all healed, so as to substitute for them movable false joints. 
Possibly, for a time, we held too hopeful views of what was attain- 
able by these operations; but wonderful cures have been accom- 
plished, and with the increased attention now given to them we may 
expect the indications, mode of operating, prognosis, and after- 
treatment to be more defined. 

In resections, the incisions should be so directed that no large 
vessels or nerves, and as few muscles as possible, may be injured, 
and still space made for freeing the joint and sawing the bone. 



RESECTIONS. 737 

When these operations were first done, they seemed so difficult that 
it was thought the joint should be exposed by large, deep flaps, so 
that ligaments and muscular insertions could be readily divided, and 
the ends of the bones sawed off. Later, as more was thought of 
making a useful joint, the operation was more carefully made ; 
oblique sections of tendons and large wounds were avoided; the 
periosteum was preserved as much as possible, and also its connec- 
tion with the muscular insertions, by using the raspatorium instead 
of the knife ; and in chronic inflammations operations were done in 
the thickened tissue, where they were followed by less inflammation 
and febrile reaction than in healthy parts. JB. von Langenbeck, more 
than any one, developed the indications for resections of joints, and 
perfected the methods of performing them ; he also introduced the 
simple longitudinal incision, which is now generally used for resec- 
tion of the shoulder, elbow, and hip ; for the knee an anterior flap 
is made, with a broad base above. 

The instruments used for resections, except the chain-saw (of 
Jeffray), are the same as recommended by Von Langenbeck : a strong 
knife, five to seven centimetres long, with straight edge and thick 
back ; this knife is introduced to the bone, and the entire incision 
made at one stroke ; with a broad, small, more or less curved, half- 
sharp raspatorium, the periosteum is scraped from the bone; the 
articular ligaments and some muscular attachments cannot always 
be detached in this way, and have to be divided close to the bone. 
When the ends of the bone have been entirely denuded of soft parts, 
they are sawed off, being held by bone-forceps, while the soft parts 
are held back with blunt hooks. Sharp edges of bone are to be 
removed with bone-nippers. 

Before the operation the patient is anaesthetized, and the limb to 
be operated on is rendered bloodless by the elastic bandage and 
carefully cleansed. After the operation the haemorrhage is to be 
carefully checked, and the wound washed with new, clean sponges ; 
then the limb is placed in an apparatus to keep it perfectly im- 
movable, but not too tight, allowing the wound to be free and the 
secretion to escape readily ; the patient's position should be easy, 
and changed without disturbing the dressing. 

I have not found it w T ell to fill the wound with charpie and apply 
a bandage before loosening the pressure above the wound ; for in so 
doing the whole bandage is so filled with blood that it must be soon 
renewed. I prefer first checking the bleeding completely by liga- 
tion, acupressure, ice-water, etc. ; then I introduce drainage-tubes, 
dipped in glycerine or carbolic-acid solution, to conduct the secretion 
into vessels placed beneath. 
47 



738 AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. 

When possible, I apply a plaster-of-Paris bandage before the 
operation, make openings of the proper size at the point of opera- 
tion, then slit the bandage down one side when it is dry and remove 
it for the operation, and have a plaster shell to put on after the 
operation, iri whidh the limb can be suspended or laid on a JRis's 
supporting splint. Other operators prefer prepared wooden or iron 
splints ; the same end may be attained with the most varied ma- 
terials. After resection of the hip-joint no bandage is usually re- 
quired, extension by weights answering the purpose. In some cases 
I have found Lister's dressing very useful. 

Resect ion- wounds are always rather complicated excavated 
wounds; they always heal by granulation and suppuration after 
a long time. This is bad for resections in feeble, marasmic patients ; 
moreover, in such patients we are never certain that caries will not 
attack the adjacent bones or the sawed surface, or- that the wound 
will not ulcerate. 

The shortest time for healing after resection will probably be 
two or three months. Indolent fistulae often remain for months or 
years. 

Recently great attention has been paid to the final result of re- 
sections of joints. The resulting false joints may become so relaxed 
that they cannot be actively moved, and the limb hangs useless ; 
other loose joints are somewhat movable ; then there are joints 
which have nearly normal mobility and power ; and lastly, anchy- 
losed joints, which are nevertheless more useful than the first men- 
tioned. 

The final result depends greatly on the amount of bone removed, 
the amount of regeneration of bone, the care observed in dividing 
the muscular insertions, and the muscular power of the patient ; it 
is also greatly influenced by gymnastic exercises, electricity, baths, 
and application of suitable apparatus. But as these vary with the 
different joints, and different methods and apparatus are required, 
these matters can only be explained when treating of resection of 
individual joints. 

Prognosis as regards life is the same as in amputations. Resec- 
tions on account of caries usually run a more favorable course than 
those for injuries. The danger increases with the proximity to the 
trunk. 






APPENDIX. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 

1.— P. 33. 

To avoid the danger from venous congestion after constricting 
the limb, before applying the tourniquet we may apply a bandage 
firmly to the extremity from below upward, and thus press the 
blood out from the limb. Formerly this procedure was applied to 
limbs about to be amputated, and thus the haemorrhage was reduced 
to a minimum. Grandesso Silvestri, a physician of Vicenza, rec- 
ommended elastic bandages for this purpose, and instead of the tour- 
niquet applied a thick elastic tube several times around the limb. 
In ignorance of this advice, which was little known, JEsmarch re- 
sorted to the same method, and called attention to the great bene- 
fits derived from it ; since when it has become very popular. In 
fact, by means of this appliance long operations may be done 
without loss of blood. The extremities may be rendered bloodless 
and kept so for an hour without injuring their vitality. After ligat- 
ing all the visible vessels, the elastic tube is to be loosened, and 
the blood will again enter the vessels ; if any more then permit the 
escape of blood, they may be ligated. This method of making a 
limb bloodless and keeping it so is a great advance in modern sur- 
gery ; and by this means operations may be done which without it 
we should not have dared to attempt. 

2.— P. 37. 

Recently I have tried the Penghawar Djambi a few times, and can 
testify that when quantities of it are pressed firmly on the wound it 
acts better than charpie as a styptic ; I will not pretend to say that it 
is better than liquor ferri, but it smears the wound less, even if left 



740 APPENDIX. 

on for some days. Penghawar Djambi is the light yellowish, soft, 
hairy substance from the trunk of the Cibotium Cuminghii, a 
native of the East Indies. [This must closely resemble the styptic 
cotton so commonly used by us. During the past year, 1878, Pa- 
quelin's cautery has been used a good deal, and is very convenient. 
By a hand-bellows a stream of benzine vapor is thrown against a 
platinum cap which has been previously heated in a spirit-lamp ; 
after it has once reached a red or white heat, it is easily kept at 
that point by the benzine vapor. It is readily used, and when at a 
white heat its application is not painful. For haemorrhages from the 
vagina or uterus, water at a temperature of 110° Fahr. may be in- 
jected for some time by means of Davidson's syringe.] 



3.— P. 57. 

Observers, who have of late persistently studied these questions, 
refer the continued capillary dilatation in acute inflammation to 
changes in the capillary walls, which are caused directly by the 
inflammation. Cohnheim claims that inflammation affects the walls 
of the vessels peculiarly, so that they are not only distended by the 
blood, but also become softer, of which more hereafter. Samuel 
ascribes inflammation to changes in the relations of the blood, walls 
of the vessels, and tissue to each other. Up to the present we have 
not succeeded in finding accurately the chemical and physical changes 
in the walls of the vessels, which are known only by their results. 
This view is an advance beyond Lotzds view (according to which 
the molecules of the capillary walls separated from nervous irrita- 
tion), inasmuch as no nerve-action seems to occur in this capillary 
dilatation developing in acute inflammation. This also corresponds 
with the demonstrations of Schiff, already mentioned, that the vas- 
cular dilatations forming after division of the sympathetic are not 
inflammatory, nor do they lead to inflammation without some fur- 
ther cause. 

4.— P. 69. 

In his history of plastic operations Zeis has collected all published 
cases of reunion of parts that had been entirely separated. Rosen- 
berg has completed this list to the present time, and gives a number 
of cases carefully observed by himself where portions of noses and 
fingers which had been cut off reunited. He confirmed previous ob- 
servations that the epidermis and occasionally small portions of the 
surface of such parts became gangrenous, while healing went on below. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 741 

5.— P. 93. 

Samuel, who in his last work on fever in general agrees in the 
etiology above given, and refers the increased temperature to in- 
creased irritation of those nerve-centres which cause production of 
warmth, denies the existence of a pyrogenous poison, and brings up 
some strong points against it ; he thinks that the blood-change 
which is the final essence of fever is always the same, in spite of the 
variety of forms under which it appears. To prevent the introduc- 
tion and removal of blood and water, etc., from being regarded as 
pyrogenous actions in the broad sense, he supposes a similar decom- 
posing tendency of the blood to exist between the products of in- 
flammation, the above-mentioned and other influences, and the ner- 
vous centre which is to be excited ; and this is termed the true final 
pyrogenous factor, the essential element of fever. 

6.— P. 126. 

The recent investigations on the formation of vessels by Arnold, 
already spoken of, as well as those on tubercle, of which we shall 
hereafter speak, have given new material for the view that the sub- 
stance of the wall of the vessel as well as its endothelium takes an 
active part in the new formation ; and in a recently published work 
of JRieclePs it is stated as very probable that the greater part of the 
young tissue formed in a thrombus proceeds from the endothelium. 
Thus the views on this subject have been unsettled for years. 

7.— P. 186. 

Fracture does not always result from the action of a strong direct 
force on a bone ; the injury may vary from contusion of the perios- 
teum to crushing of the bone. There may have been merely com- 
pression of the periosteum, or the force may have bent the bone, 
which sprang back to its normal shape without breaking ; but at the 
same time the medulla may have been greatly crushed. In the 
spongy substance there may be slight breaks or bends, which are 
never entirely dissipated, even though the cortical substance has not 
perceptibly changed its form. All these injuries of bones resulting 
from strong compression are classed as contusions of bone. Concus- 
sion of bone may result from either direct or indirect force, and be 
marked by ruptures of the medulla and haemorrhages. After these 
injuries, pains and disturbance of function are greater than after 
injuries of the soft parts ; a certain diagnosis of the grade is often 
impossible at first. Occasionally concussions of bone with contusion 



742 APPENDIX. 

(as in falls on the great trochanter) result in long-continued ostitis, 
which is not often accompanied by suppuration, but by formation 
of osteophytes, sclerosis, and protracted impairment of function, 
which in old persons may prove permanent. 

8.— P. 235. 

Some surgeons praise very highly rubbing and kneading of the 
extravasation of blood immediately after the injury ; this is an old 
popular remedy, used even by the Grecian gymnasts ; now it is called 
massage. Wonders are told of the efficacy of this treatment, espe- 
cially in regard to rapid reabsorption and restoration of function. 
The resolvent effect is particularly noticeable in the first four or six 
hours ; later, when acute inflammation has already occurred, I would 
recommend it less ; but when this stage is past, it may be more 
energetically employed. 

Unfortunately, even after the most careful treatment of sprains, 
chronic inflammations occur, which are not only tedious on account 
of their duration, but, continuing through years, may lead to de- 
struction of the joint ; this is more apt to occur in children or feeble 
persons of scrofulous diathesis. We shall again refer to this when 
speaking of the etiology of chronic inflammations. 

9.— P. 275, 

Recent investigations of Samuel show that after certain grades 
of freezing there is a true inflammation which goes on to regular 
gangrene. From clinical experience I knew that in such cases there 
is a process not found in burns ; for parts badly burned, even when 
not turned to cinder, shrivel up, and the blood coagulates in the 
vessels, so that other blood cannot enter them even if they continue 
to exist. If a frozen limb thaws for a time, arterial blood may again 
enter the vessels, and the question will be whether the walls of the 
vessels can still keep the blood fluid and the tissues use up the blood 
coming to them. If this be so, the frozen limb may regain its vital- 
ity ; if it does not, gangrene occurs. In this transition stage the 
veins are much distended, and this may facilitate thrombosis in them. 
Bergmann recommends particular attention in the treatment of this 
stage ; he has had unusually good results from vertical suspension of 
the limb, which favors the return of the venous blood. 

10.— P. 284. 

This limitation of the process to the skin and subcutaneous cellu- 
lar tissue is very characteristic of fibrinous (diphtheritic) inflamma- 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 743 

tions ; so that on this account, as well as from the hard infiltration 
and necrosis of the tissue once infiltrated, I do not hesitate to con- 
sider carbuncle as a diphtheritic inflammation of the skin. I have 
had no opportunity of examining to see if there are micrococci in the 
freshly-expressed juice of carbuncle ; finding a few of them in the 
exposed shreds of necrosed tissue would prove nothing about the ori- 
gin of the carbuncle. ITochmann thinks that carbuncle as well as 
furuncle originally develops from a sweat-gland, or from several ad- 
jacent glands. J. Neumann distinguishes between carbuncles from 
sweat-glands and from cellular tissue. I cannot say whether there 
is any justice in this distinction, as I too rarely see carbuncle in its 
first stages. 

11.— P. 285. 

The inflammation here described cannot be considered exactly as 
carbuncle ; it is rather a carbunculous inflammation of the skin and 
subcutaneous tissue, which I should now prefer to call diphtheritic 
phlegmon ; the accompanying erysipelatous redness also corresponds 
with diphtheritis. 

12.— P. 286. 

The great difference of the constitutional symptoms in carbuncle 
agrees very well with the supposition that they are of diphtheritic 
nature, where it is characteristic for the local extent not to corre- 
spond to the general toxic symptoms. I do not know if paralyses 
ever occur after carbuncle, as they do after pharyngeal and laryngeal 
diphtheria. 

13.— P. 286. 

Possibly patients attacked by carbuncle were only apparently 
well ; they may previously have had diabetes of a mild grade, with- 
out its existence having been suspected by themselves or their phy- 
sician. 

14.— P. 296. 

You will often hear that early incisions in phlegmonous inflam- 
mation will prevent the skin from becoming gangrenous or suppu- 
rating. Unfortunately, I cannot confirm this. I have found it to 
depend more on the intensity of the inflammation than on the ten- 
sion of the skin. Still, I consider early incisions proper in phleg- 
monous inflammation, as it seems that by carefully pressing the 
serum out of the inflamed tissue we may sometimes arrest the pro- 
gress of the affection. 



744 APPENDIX. 



15.— P. 297. 



The abnormal position of extremities after abscesses in muscles 
have healed is due to formation of cicatrices and their imperfect dis- 
tensibility. 

16.— P. 306. 

My saying that I could not imagine an acute inflammation of 
bony tissue has caused some misunderstanding. In acute inflamma- 
tion of bone no changes are observed in the (fully developed) osseous 
tissue, but only in the medulla and periosteum and their vessels. I 
do not underestimate the chemical changes (disturbances of nutri- 
tion) which go on in the tissues during inflammation ; but we do 
not know them : we only conclude they occur from the changes we 
see in the tissues. We see that inflamed connective tissue swells, 
becomes cloudy, is infiltrated by wandering cells, softens, and finally 
breaks down into pus ; and all this occurs within a few days. In 
bony tissue we see' none of these changes ; we do not see that it 
swells in acute inflammation, or that its interspaces (except the 
Haversian canals) fill with wandering cells ; and we know that it 
does not suddenly break down into pus. We only know one termi- 
nation of acute inflammation of bone, that is, death — necrosis ; be- 
sides this, it may pass on into chronic inflammation. Hence we can 
only say it is probable that in acute inflammation of bone changes 
of nutrition occur, as in that of connective tissue ; but there is, or 
rather from the nature of bone-tissue there can be, no morphological 
expression for this change. 

17.— P. 316. 

At the opening of this chapter I said: "The immediate cause of 
death of individual parts of the body is always the complete cessa- 
tion of the supply of nutriment, mostly due to arrest of circulation 
in the capillaries." This admits the possibility of gangrene occur- 
ring in tissues where capillary circulation still continues. Formerly 
this seemed to me impossible ; I could not imagine a dead gangre- 
nous tissue with capillary circulation. But observations at the bed- 
side, together with the impressions derived from SamueVs investiga- 
tions of inflammation, have made it seem to me probable that the 
inflammatory disturbance of nutrition of which we have spoken occa- 
sionally starts up and extends so rapidly that it leads directly to 
arrest of the vital change of tissue, even before the occurrence of 
stasis and coagulation in the capillaries ; the blood then circulates in 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 745 

tissues which fulfill no normal function of interchange of tissue, but 
in which the juices are being decomposed in an abnormal way, which 
may even be the same as putrefaction. Paronychia and more rarely 
phlegmons sometimes pass so rapidly to gangrene, that from analogy 
with other processes it seems very improbable that they should be 
due to arterial thrombosis ; when the tissue has become gangrenous, 
the capillary circulation soon ceases, but not from disturbance of the 
circulation in the arteries and veins, as in gangrene from incarcera- 
tion, but from arrest of function of their walls from the inflammatory 
process, which I regard as a higher grade of the inflammatory altera- 
tion (Cohnheim) that takes place rapidly in such cases. It seems 
that such a rapid change from inflammatory alteration to destruction 
of tissue is particularly apt to follow septic poisoning ; possibly snake- 
poison acts in the same way. More of this hereafter. Here we must 
again mention the fibrinous infiltrations of the cellular tissue (diph- 
theritic phlegmons). Some clinical observations seem to show that 
fluid blood can continue to flow for a time through the vessels of 
tissues whose juices have nearly hardened, that in some of these 
cases the thrombosis is only the result of the infiltration of tissue, 
and that the tissue sometimes dies before the circulation is fully 
arrested. At present we cannot fully explain this symptom ; I only 
wished to induce you when opportunity offered to attend to these 
practically important processes.. The view is not new, for the old 
surgeons regarded gangrene as the highest point of inflammation. 

18.— P. 355. 

Besides the mechanical cause of the compression, which favors 
coagulation, in inflammation of any tissue there is another factor 
having the same effect, namely, the changes in the intima of the 
vessels, especially of the veins. If we do not know the positive 
chemical conditions under which the blood in the vessels must coag- 
ulate, since the classical investigations of JBrucke we do know that 
the normal living intima of the vessels has the special property of 
keeping the blood fluid, and that coagulation occurs when the intima 
loses its normal qualities. But in the veins, as in the capillary walls, 
it loses its normal qualities through inflammation, as is shown by 
the more recent investigations (see Lecture XXII.) ; these show, 
indeed, that the inflammatory alteration of the walls of the vessel 
does not of itself at first induce either complete stasis or thrombo- 
sis ; however, it is not improbable that the latter is at least favored 
by the alteration of the walls of the vessel. Hence, the recent views 
on inflammation would, in some cases at least, confirm the old view 



746 APPENDIX. 

that inflammation of the walls of the veins may cause thrombosis 
(even without leading to abscess in their walls) ; but further inves- 
tigations in this direction are desirable. Clinical observations also 
speak in favor of such a course ; for it has been proved that peri- 
phlebitis (analogous to perilymphangitis) often precedes phlebitis 
and thrombosis. 



19.— P. 361. 

Then you will also be told how to distinguish small lobular infil- 
trations of the lump, such as occur in purulent bronchitis, from me- 
tastatic abscesses. I will merely mention here that where a venous 
thrombus opens into the wound, it may remain firmly organized 
while its upper part suppurates, breaks down, and is finally swept 
into the circulation by the neighboring branches in which the blood 
circulates ; this is the only case where pus from the veins enters the 
circulation without there having been haemorrhage. After death we 
recognize this process by finding fluid blood or fresh post-mortem 
clots in the thickened veins, whose inner walls are rough from ad- 
herent layers of the thrombus ; if there has been periphlebitis, and 
the portion of vein has suppurated, we cannot decide with absolute 
certainty that there has been a previous suppuration of the thrombus. 



20.— P. 372. 

The severest cases are those where toward the middle or end of 
the second day great cyanosis and collapse come on rapidly ; then 
death usually occurs in a few hours. Such patients look like those 
in the algid stage of cholera, only in septicaemia vomiting and per- 
sistent diarrhoea are rare ; after getting along well perhaps for 
twenty-four hours after the operation, the patients seem as if poi- 
soned. In these cases (which may be accompanied by diphtheria) 
the secretion from the wound does not always smell disagreeably. 
It cannot be shown that the intoxicating matter in these cases is 
different from usual, or that the inflammatory alteration of tissues 
causes a remarkable amount of poisonous product. According to the 
above, the variety of symptoms in septicaemia is considerable ; but 
this proves nothing against the claim that the septic poison is always 
the same, for there is the same difference from cholera, carbuncle, 
diphtheria, and bites of serpents, in which cases we do not assume dif- 
ferent natures, but only differences of intensity and in the quantity 
of poison absorbed, and difference of resisting power in the patients. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 747 



21.— P. 373. 

Some surgeons prefer to say that a patient who has been wound- 
ed or operated on has died of severe typhous traumatic fever, instead 
of using the term " septhsemia " or " septichaemia." This is an in- 
correct expression even if it were practically true. " Typhous " is 
used in the old sense, like the rvtyoq of Hippocrates, for stupid ; later 
the term typhous was applied to fevers in which the patient was 
stupid; during the last twenty years well-characterized infectious 
diseases have been called " typhus." It is better to use the name 
thus, and not bring the term typhous into use again. Virchow uses 
"ichorrhaemia" in the same sense that I do septicaemia; l%^>9 means 
blood-water, lymph, serum of wounds ; the older surgeons occasion- 
ally apply the term to thin, bad pus. 

22.— P. 386. 

The cause of this is said to be that the septic matter, once taken 
into the blood, acts as a ferment, and that a small quantity suffices 
to cause decomposition of the blood and all the juices. As already 
stated, I do not consider this haematozymotic action of septic poison 
as proved ; on the contrary, I think that it, like the poison of diph- 
theria, malignant pustule, etc., often acts for so long a time and so 
differently, even when taken up in small quantities, because the hu- 
man organism (as well as that of some animals) only sets it free very 
slowly, and because at the points where it is retained in the body it 
often excites new foci, where the poison forms anew (perhaps less 
intense). For instance, I think dogs can bear so much septic poi- 
son because they pass it off so rapidly by the bowels ; they thus es- 
cape even very severe putrid infection. The power of getting rid 
of absorbed infecting poison more or less rapidly may vary with the 
individual to some extent. The same view would hold in typhus, 
cholera, and the acute exanthemata. 

23.— P. 430. 

The rapid absorption of old torpid infiltrations is sometimes very 
favorably affected, as are neuralgic pains in chronically inflamed 
parts, by warm or hot local mud-baths. In some parts of Hungary 
hot springs open into the mud of small streams ; in this natural hot 
mud, which is used in tubs, the diseased limbs are soaked once or 
twice daily ; similar baths are prepared artificially. The bog-baths 
at Franzenbad and Marienbad are about as efficacious; the bog, 



748 APPENDIX. 

soaked with ferruginous water, is warmed and used as the mud-baths 
above described. We do not know whether the mineral salts con- 
tained in the bath have any effect ; they probably act only as large 
cataplasms. Compresses wet with thermal water of iodine-springs 
have also a good reputation as resorbents. Usually they soon induce 
cutaneous eruptions, and may also be considered as derivative reme- 
dies. Animal-baths are also very popular; in these the diseased 
limb is placed among the intestines of an animal just killed, and kept 
there till the dead body is cold ; a peculiar effect is claimed for the 
animal warmth, of which I have been unable to convince myself. 
Lastly, we must mention hot sand-baths, which were formerly very 
popular ; these probably have no advantage over moist warmth. 



24— P. 473. 

In these earlier stages massage may be carefully tried. You will 
accomplish but little by these therapeutic efforts ; you will find that 
as long as adult patients, can tramp around on their diseased bones, 
they will do so ; when you tell the patient that it is not certain the 
disease will get well if he lies quiet a few weeks, but that it will last 
months or years under careful treatment, he will attend to his busi- 
ness as long as possible. If the existence of your patient's family 
depends on his daily work, his case is very hard. It is just as hard 
to keep children constantly quiet ; a grown person must watch them 
all day. This is impossible, not only among the poor, but in large 
families among those in moderate circumstances. It is very easy to 
say the child must lie still several months, except when it is care- 
fully taken into the fresh air in a wagon or laid in a shady part of 
the garden during fine weather ; but if this has to be done for years, 
it is very expensive, for it requires the whole time of a careful adult 
nurse. This daily, hourly care for securing the best hygienic and 
dietetic conditions to a child with chronic disease, requires unusual 
patience and intelligence. Sacrifices are much more readily made 
for expensive medicines, or going to watering-places, to get the 
trouble over quickly. In such cases we must consider the circum- 
stances, so as to secure the best thing possible ; we may order me- 
chanical supports to keep the weight of the body off the bones. I 
give you these hints, so that you may not be too much disappointed 
in your future practice. You will often see that many chronic dis- 
eases which are not incurable never are cured, on account of some 
social reason. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 749 



25.— P. 505. 

Among the local sj^mptoms I may add that for each joint certain 
muscles gradualty become permanently contracted ; usually it is the 
flexors ; in the hip-joint the adductors and rotators are also affected, 
and the joint is permanently held in such a position as to give lit- 
tle or no pain. If these pathological positions are caused by the 
muscular contraction alone, and have not continued too long, they 
may at once be overcome by anaesthesia. But after months or years 
atrophy begins in the fasciae, and afterward in the muscles, which 
even under anaesthetics can only be broken up by force. After long 
disuse the muscles are greatly atrophied by fatty degeneration and 
cicatricial contraction. The articular capsule too, which was much 
infiltrated and swollen, as well as the accessory ligaments, also con- 
tract on the side toward which the joint has been bent ; thus, in the 
case of the knee-joint this contraction would be greatest in the hol- 
low of the knee. 

Cases where the disease begins with a seropurulent effusion in the 
joint (catarrhal, blennorrhoeal synovitis) are rare. I have seen them 
chiefly in tuberculous patients. The symptoms are at first the same 
as in chronic dropsy of the joint, but the joint is painful and its 
function more impaired. Comparatively often ostitis and periostitis 
near a joint are the causes of synovitis ; one or other side of the 
condyles of the femur, tibia, or humerus, or the posterior surface of 
the olecranon, become painful ; the pain remains localized for some 
time at one point ; then there is a doughy oedema, and finally an 
abscess. Meantime the functions of the joint may remain unim- 
paired for months, till the suppuration (occasionally with acute in- 
flammatory symptoms) attacks the joints ; then the course above 
described begins. In some cases these abscesses always remain 
periarticular, and heal before the joint is opened ; this might cause 
periarticular cicatricial contraction, while the joint was perfectly 
healthy. 

Lastly, the bones may be primarily attacked by ostitis malacis- 
sans ; this occurs particularly in the carpus, tarsus, and caput femo- 
ris of feeble patients ; the joints may long remain unaffected, even 
if periosteal abscesses with great oedema and suppurating fistulae 
form. In primary diseases outside of the epiphyses muscular con- 
tractions are less apt to develop than in primary disease of the syno- 
vial membrane and primary subchondral ostitis. 



750 APPENDIX. 



26.— P. 515. 



As yet I have no experience of the value of massage in the com- 
mencement of tumor albus ; it should be used with great care. I 
cannot help thinking that massage used too strongly in these cases 
might induce suppuration where there was any tendency to it ; so I 
would only recommend this treatment in torpid cases. 

27.— P. 515. 

When the means of the patient admit, and there is a good dresser 
at hand, these bandages may be replaced by light splints, which do 
not require the joint to be kept quiet, but free it from the weight of 
the body as much as possible. In this direction mechanical surgery 
has made great advances ; by its aid, even in diseases of the lower 
extremities, many patients may be enabled to move about. 

28.— P. 516. 

There is no doubt that in most cases of commencing and pro- 
gressing diseases of the joints traction is more efficacious than plas- 
ter bandages ; hence, in my clinic you will see it used more fre- 
quently ; but in private practice you will not persuade all patients 
to go to bed, and moreover the method requires such careful watch- 
ing from the surgeon as to interfere with its employment. Taylor, 
an ingenious American surgeon, has constructed splints for the lower 
extremity by which traction may be so applied as to free the joint 
from pressure and enable the patient to go about. These splints 
often act excellently, but they are difficult to make, and their use 
requires certain experience on the part of the surgeon. All of these 
mechanical aids — plaster dressings, supports, traction, Taylor's splint, 
etc. — require continued supervision to prevent injury from pressure 
and friction and from displacement of the apparatus. In the case of 
children great patience and perseverance are needed in judging 
whether the extension is enough or too great, to accustom them to 
the inconvenience of the apparatus, to quiet the anxiety of the par- 
ents when the child cries, and by friendly talk or sober, earnest ef- 
forts to make the children obedient and prevent their loosening the 
apparatus. This treatment can rarely be thoroughly carried out in 
private practice ; hence, treatment in hospitals or orthopedic institu- 
tions cannot be too strongly urged, at least until the chief dangers 
from deformity are passed. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 751 



29.— P. 523. 

Less attempt is made than formerly to obtain movable false 
joints after resection ; but more frequently we seek by partial re- 
moval of the bones chiefly diseased under Lister's method, and with 
the least possible suppuration, to cause anchylosis of the joint. 

30.— P. 523. 

Unfortunately, return of the disease is not rare, even in joints 
which had been healed by anchylosis for years. Persons who have 
suffered from the above forms of chronic articular inflammation 
rarely attain old age. You will find few persons above forty or fifty 
years old with anchylosis from tumor albus. This seems another 
proof that these diseases are associated with some constitutional 
taint, difficult as it is in all cases to prove this, and to demonstrate 
it to those who are inclined to explain all diatheses and dyscrasise as 
vague theories of old physicians. 

31.— P. 524. 

Tedious and painful as they are to the patient, they are not as- 
sociated with severe constitutional affections, such as tuberculous 
and lardaceous diseases ; hence they are rarely fatal, and are less dis- 
eases of youth than of mature age. 

32.— P. 577. 

Careful examinations of veins by Soboroffh&ve shown that their 
walls are in very different conditions ; he examined especially the 
saphenous vein and its branches ; he found that normally in differ- 
ent persons its layers varied essentially, and that even adjacent 
parts of the same vein were not exactly alike. This is very interest- 
ing, for it explains why the occurrence of varices is so unequally in- 
duced by the same cause, and is due to purely individual circum- 
stances. Among varicose veins we may distinguish those with thin 
and those with thick walls. The enlargement of the muscular fila- 
ments and the lack of change in the endothelium are common to all. 
The variation in the diameter of the walls of the veins is chiefly due 
to thickening of the adventitia, whose vessels also increase, and of 
the cement which unites the muscular filaments; slightly also to 
thickening of the intima ; but sclerosis of the latter, as in arterial 
sclerosis, is very rare. Hence, under increased pressure the anatomi- 
cal conditions in the walls of veins are the same as in the urinary 



152 



APPENDIX, 



bladder and heart under similar circumstances. At first, in conse- 
quence of increased functional demands, the muscular filaments seem 
to grow ; if then nutrition is increased by increase of the vasa vaso- 
rum, the connective tissue, especially the adventitia, is decidedly in- 
creased ; if the nutrition be not increased, there is atrophy and total 
relaxation. 

33.— P. 651. 

The following forms of sarcoma are of developed connective tis- 
sue, whose form depends greatly on the vessels : 

(g.) The (infiltrated and superficial) villous sarcoma, pearl-tu- 
mors, and psammona. As is well known, the serous membranes 



Fig. 139 a. 




From a villous sarcoma (cancroid of Arndt) of the pia mater, a, Commencing cell-infiltration in the 
capillary walls ; 6, clubbed proliferations growing: from the walls of the vessels ; c, the same 
covered with a thick layer of endothelium ; d, endothelial cells of the highest development, not 
to be distinguished from epithelial cells ; e, conglomeration of these cells into a spherical shape. 
Endothelial pearls. Magnified 400. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 753 

have the peculiarity in some pathological processes of forming ragged 
proliferations, whose basis is connective tissue and ultimately ves- 
sels, and whose covering consists of multiplied and enlarged endo- 
thelial cells. Well-developed shreds of synovial membrane in arthri- 
tis deformans, shreddy proliferations of the pericardium and endo- 
cardium on the valves, the plexus choroidei, and the Pacchionian 
granulations of the cerebral membranes, are the types of this neo- 
plasia. The tumors which to a certain extent may be regarded as 
the highest stages of development of this variety are only found in 
the membranes of the brain or the nerve-sheaths directly proceeding 
from it ; some of these neoplasias have a villous character, at least 
exteriorly ; others form compact masses, the dendritic tissues grow- 
ing through each other. 

These tumors form thus : A circumscribed cellular infiltration (a, 
Fig. 139 a) begins in the adventitious sheath of the vessel, which 
gives rise to clubbed, shreddy outgrowths, which soon become hya- 
line or filamentary connective tissue, and then develop a cavity in 
them, which gradually unites with the caliber of the vessel (b). Part 
of the cells assume epithelial forms and envelop the above club- 
shaped neoplasias (c). Between these cell-masses we find spheres of 
flat compressed cells (e), which in part become dry and under some 
conditions even calcareous. Whether the pearl-tumors ( Virchow) 
starting from the cerebral membranes, which are composed of pearly 
non-vascular nodules from the size of a millet-seed to a pea, are com- 
posed of such endothelial spheres, or are true epithelial formations, 
I shall not attempt to decide, as I have made no personal observa- 
tions, and there has been nothing published on this point recently. 
According to Virchow 's investigations, the pearls of the intracranial 
tumors are composed of connective-tissue cells ; hence they should 
be classed with sarcomata. Thymus pearls are the physiological 
examples of this form, which from their non-vascularity also have an 
analogy to tubercle. 

Another tumor described by Virchow and renamed belongs here, 
the psammona. This also has only been observed in the brain or in 
the orbit, and is related to the villous and to plexiform sarcoma, 
which we shall soon describe. This variety of tumor is characterized 
by the occurrence of calcareous spheres, having the form of the con- 
crements which are found in the pineal gland, and are there known 
as brain-sand (Trcra/x/zoc, sand). Like the thymus pearls, these are 
mostly connected with the vessels, and are probably mostly calcified 
endothelial pearls; but Virchow says that direct calcification of 
connective tissue may lead to the same forms. 

(h.) Plexiform (cancroid, adenoid) sarcoma. This form of sar- 
48 



754 




Psammona, after Virchow. Magnified about 200. 



coma also is chiefly found in the orbit and brain, but sometimes oc- 
curs in the parotid gland. It can only be distinguished by very 
careful examination from some forms of carcinoma to be hereafter 
described. Plexiform cylinders, clubs, and spheres of small cells 
spread out in the connective tissue, separating its bundles and filling 
all the interspaces between them, in doing which they naturally push 
into the lymphatic vessels and perivascular lymphatic spaces. It 
cannot always be determined whether the cells first increasing are 
wandering cells, connective-tissue cells, or cells from the walls of the 
vessels, endothelium, or perithelium ; perhaps they all participate at 
the same time or after one another. 

The cells first proliferated are as a rule small, round, or irregu- 
larly polygonal ; gradually the following often complicated meta- 
morphoses occur in these cell-cylinders: Vessels grow into them, 
the middle part of the cells around the vessels becomes hyaline or 
filamentary connective tissue, the outer cells form a covering for the 
vessel and the central neoplastic connective-tissue filaments. So 
these formations have a sort of villous shape, which has grown into 
the tissue (interstitial papillary proliferations, interstitial papillary 
myxoma^Rindfleisch). At the same time the enveloping cells assume 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 
Fig. 139 c. 



755 




a , From a cerebral tumor, after Arnold, b, From a cerebral tumor, after Bindjleiscli. Magnified 

300-400. 



such exquisite epithelial forms and positions that they may very 
readily be mistaken for sections of glands, especially when very 
slightly magnified (#, Fig. 139 c). 

Very peculiar forms occur when some of the cells in the primary 
cell-cylinders, by transformation of their protoplasm, become hyaline 
connective tissue («, a, a, Fig. 139 d). Then connected, dendritic, 
cactus-like formations enveloped in cells (but capable of being freed 

Fig. 139 d. 




Commencing hyaline metamorphoses in the early stages of a plexiform sarcoma. Commencement 
of the formation of cylindroma. After Sattler. Magni tied 500. 



756 



APPENDIX. 



from them) result ; vessels may grow into them, if the neoplasiae did 
not start from the vessels or grow around them. These peculiar 
hyaline clubs and cylinders were formerly regarded as lymphatic 
vessels. I recognized this error early, and took them for hyaline 
connective tissue, and from the hyaline cylinders called the tumor 
" cylindroma." But their commencement remained obscure ; the 
cylinders, composed wholly or chiefly of cells, I took for glandular 

Fig. 139 e. 




From a cylindroma (plexiform sarcoma with hyaline vegetations) of the orbit. Magnified 300. 

formations ; hence the mode of development of these new forma- 
tions remained doubtful for myself and some other observers, who 
had the opportunity of examining such tumors. Later I wavered 
a good deal over the significance of these things and their genetic 
combinations. Sattler's investigations first threw a clear light on 
the subject. The explanation just given seems to me the more 
probable, as it gives the key for explaining many varieties of these 
tumors. 



34.— P. 664. 

Quite lately the investigations of Bizzozero and Neumann have 
shown an intimate relation between leucocythemia and disease of 
medulla of the bones, where according to the views of these ob- 
servers the transformation of colorless into red blood-cells should 
normally take place; so that leucocythemia would be due to this 
transformation being prevented from any cause. 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 757 



35.— P. 664. 

A. von Winiwater in a recent work has drawn a very sharp boun- 
dary between malignant, rapidly-growing lymphomata and primary 
medullary sarcomata in the lymphatic glands (lymphosarcomata). 
The former are said always to come in several lymphatic glands of a 
part (especially of the neck) at once, long continue movable, but 
finally unite into one mass ; later other groups of lymphatic glands 
are attacked, and lastly internal organs. Two varieties may be dis- 
tinguished, one softer and grayish-red on section, the other firmer, 
fibrous, and more white on section ; the latter runs the more rapid 
course; both forms of malignant lymphoma are always fatal. 
Lymphosarcomata are either round-celled or spindle-celled; they 
come first in a gland ; the surrounding tissue is gradually affected, 
so that the tumor soon becomes immovable ; metastases to the lungs 
and spleen are common. I regard these distinctions as generally 
correct and grounded on careful observation, but believe that com- 
binations of the two forms are not rare. 

36.— P. 674. 

By a choice of cases, the results of my thyroid operations have 
continuously improved. XUcke, Stork, and Schwalbe praise paren- 
chymatous injections of tincture of iodine or alcohol; this is said to 
cause a considerable or even total shrinkage of the struma. In the 
first cases where I used these parenchymatous injections of tincture 
of iodine, they had no effect; one case where I injected alcohol 
proved fatal from suppuration of the goitre and septicaemia. Lately 
in some cases I have obtained considerable diminution of the goitre 
by persistent injection of iodine; twice a week I inject one gramme 
of pure tincture of iodine; this must be continued several months. 
Under this treatment some patients emaciated greatly, so that I 
would not recommend it in feeble or tuberculous patients. Since 
the above-mentioned unfortunate case I have not tried alcohol injec- 
tions. Stork also has informed me that alcohol injections sometimes 
excite considerable inflammatory reaction, while after injections of 
iodine there is merely a temporary swelling and pain ; it is prudent 
at first to inject a third, then a half syringe full, to test the individ- 
ual susceptibility of the patient. 

37.— P. 683. 

This view also finds supporters among the new school, who either 
do not recognize the typical formation of the tissue from the germ- 



758 APPENDIX. 

layers, or else do not acknowledge its significance for the pathologi- 
cal neoplasias. Since this question was first earnestly discussed it 
has come up repeatedly, not only in the same generations, but to the 
same person. I cannot here repeat all that I have said about the 
origin and increase of true epithelia ; I will merely add that the car- 
cinomatous and epithelial forms found in primary cancer are also 
invariably found in the infecting tumors in the lymphatic glands. 
This seems to speak strongly in favor of the traveling of cellular 
elements, for it is scarcely probable that the fluid from a columnar 
epithelial cancer should influence the cells in the lymphatic glands 
to produce cylindrical epithelium. 

38.— P. 684. 

From the above peculiarities even in the most difficult cases, we 
may always find the genetic differences between sarcoma and carci- 
noma. The first commencements of sarcoma and carcinoma are often 
scarcely distinguishable (compare Fig. 139 B with 162 and 163) ; 
both cases are very glandular in formation. But things change after 
a time ; the cell-cylinders of the sarcoma have either started from 
vessels, or vessels soon grow in them ; while this never happens in 
carcinoma, but the cylinders, even when quite large, remain without 
vessels, or else a cavity forms in them as in the development of 
glands (compare Fig. 139 b with 169). 

I dare not enter further into the general histological description 
of these tumors, and hope you will be able to recognize them. 

39.— P. 685. 

When speaking of sarcoma I said something about the difference 
of its course from that of carcinoma. I here repeat again that the 
latter always first affects the adjacent lymphatic glands ; often the 
infection does not extend beyond them ; in other cases there may be 
metastatic tumors in internal organs or the bones. The small epi- 
thelial germs find the most favorable soil for their development in 
the lymphatic glands. The rapidity of the course varies exceeding- 
ly ; this we shall consider more closely when treating of the topogra- 
phy of carcinoma. 

In most cases no cause for carcinoma is discovered ; sometimes it 
has been preceded by injury or ulceration. My observation does not 
confirm what we hear and read about cancerous cachexia and the 
peculiar appearance of the patient. A person with cancer finally 
becomes marasmic, just like any one else who has severe disturbance 



ADDITIONS FROM THE EIGHTH GERMAN EDITION. 759 

of the function of some important organ, and who absorbs particles 
of decomposing matter ; he becomes anaemic from haemorrhages, dis- 
turbance of digestion, and lack of nutrition ; then he emaciates rapid- 
ly and acquires the waxy, brownish hue (which in some complexions 
is a brownish green). But I have never been able to discover any- 
thing peculiar in these cases. There is no proof that such patients 
giye off any infecting substance, as is sometimes believed. 



REGISTER OF NAMES. 



PAGE 

Abernethy, John (f 1831, ia London) 475 

Abulcasem(f 1106) 7 

Aeby (professor of anatomy in Bern) 57 

jEsculapius 4 

Albert (professor of surgery, Innspruck) 361 

Alexander of Tralles (525-605) 6 

Alexandrian school 6 

Anel, Dominique (surgeon in Turin, beginning of eighteenth century) 591 

Antyllus (third century) 6, 592, 593 

Amabile (professor in Naples) 97 

Arndt (teacher in Greifswald) 649 

Arnold, J. (professor of pathological anatomy at Heidelberg) . 64, 66, 67, 116, 317, 598 

Asclepiades 4 

Aselli (1581-1626) , 10 

Auerbach (teacher in Breslau) 57 

Avenzoar (1126) 7 

Avicenna (980-1037) 7 

Bardeleben (professor of surgery in Berlin) 107 

Barensprung, von (1822-1864) 89 

Barton, Rhea (Philadelphia) 232, 556 

Bartscher (physician in Westphalia) 101 

Barwell (London surgeon) 575 

Baum (professor of surgery in Gottingen) 37, 172, 665 

Baynton (English physician) 441 

Beck 263 

Becker, Otto (professor of ophthalmology in Heidelberg) 710 

Bell, Benjamin (1749-1806) 11, 137 

Bellocq, Jean (1732-1807) 35 

Bergmann (professor of surgery in Dorpat) 361, 369, 742 

Bernard, Claude (professor of physiology in Paris, f 1878) 56 

Bernhardt, M. (physician in Berlin) 91 

Biermer (professor of the medical clinic in Zurich) 385 

Bilguer, John Ulrich (1720-1796) 12 

Bizzozero (professor of pathological anatomy in Padua) 756 

Boinet (surgeon in Paris) 527 



REGISTER OF NAMES. 761 

PAGE 

Bollinger (of Munich) 398 

Bonnet (surgeon in Lyons, f 1863) 13, 238, 311, 403 

Bouvier (surgeon in Paris) 552 

Boyer, Baron (1747-1833) 12 

Branca (fifteenth century) 8 

Brasdor (1721-1799) 591 

Braunschweig, Hieronymus (born 1430) 10 

Breschet, G. (j 1845) 582 

Breslau (1829-1867) 386 

Broca (professor of surgery in Paris) 591 

Brodie, Sir Benjamin (1783-1863) 13, 545 

Bromfield, William (1712-1792) 27 

Brown-Sequard (physician in Paris) 118 

Briicke, E. (professor of physiology in Vienna) 143, 592, 745 

Bruns, von (professor of surgery in Tubingen) 33, 205, 735 

Brunschweig (born 1430) 10 

Bubnoff (physician in Russia) 125, 358 

Buck, Gurdon (New York) 206, 592 

Buhl (professor of pathological anatomy in Munich) 288, 399, 422 

Burow (professor of surgery in Konigsberg) 101 



Celsius 89 

Celsus, Aulus Cornelius (25 b. c. to 45 a. d.) 56 

Chassaignac (surgeon in Paris) 155, 176, 475, 735 

Chauliac, Guy de 735 

Cheselden, William (1688-1793) 11 

Chopart, Francois (1743-1795). 523 

Ciniselli 592 

Civiale (1792-1867) 13 

Cohuheim (professor of pathological anatomy in Kiel). . 61, 196, 201, 317, 323, 

404, 508, 576, 740, 745 

Cooper, Sir Astley (1768-1841) 12, 53, 136, 681 

Coote 591 

Cruveilhier (professor of pathological anatomy in Paris) 352, 354, 543, 578 

Czerny (professor of surgery in Freiburg) 97 

Dalton, J. C, Jr. (New York) 599 

Davaine (professor in Paris) 370, 398 

Delpech (1772-1832) 12, 564 

Demarquay 264 

Desault, Pierre (1744-1795) 11 

Dieffenbach, Johann Friedrich (1795-1847) 12, 37, 39, 45, 112, 134, 229, 

402, 444, 529, 552, 631 

Dittle (professor of surgery in Vienna) 131, 735 

Dolschenkow (Russian surgeon) 343 

Dorsey (Philadelphia, 1783-1818) 137 

Dubois-Reymond (professor of physiology in Berlin) 55 

Duchenne (de Boulogne) (physician in Paris) 574 

Dupuytren, Baron (1778-1835) 12, 192, 332, 572 



762 • REGISTER OF NAMES. 

PAGE 

Ebert (professor of diseases of children in Berlin) 343, 606 

Eberth (professor of pathological anatomy in Zurich) 57 

Ehrlich (of Vienna) , 349 

Eichhorst (of Konigsberg) 116 

Eschricht (of Copenhagen) 559 

Esmarch, Friedrich (professor of surgery in Kiel) 179, 393, 430, 474, 517, 

545, 546, 725, 739 
Eustachio (f 1579) 10 

Fabry von Hilden (1560-1634) 10, 37 

Falopia (1490-1563) 10 

Fick, Adolph (professor of physiology in Wiirzburg) 390 

Fischer (professor of surgery in Breslau) 341, 369 

Flourens (1791-1867) 490 

Fook, Carl (1828-1863) 341, 544, 545 

Foliin (1823-1867) 13, 451 

Fox, Wilson (physician in London) 423 

Frey (professor of zoology in Zurich) . 664 

Frisch (professor of anatomy, Vienna) 343 

Froriep, Robert (1804-1861) 119, 120 

Galenus, Claudius (131-201) 6 

Gersdorf, von, Hans (1520) 10 

Goll (physician in Zurich) 388 

Golubew (Russian physician) 55 

Graefe, von, Carl Ferd. (1787-1840) 12, 40 

Graefe, von, Albrecht (professor of ophthalmology in Berlin) 393 

Gross, S. W. (of Philadelphia) 471 

Guido de Cauliaco (fourteenth century). . .. 8 

Gurlt (professor of surgery in Berlin) 193 

Gussenbauer (professor of surgery in Liege) 65, 114 

Giiterbock (of Berlin) 65 

Halford (of Australia) 394 

Haller, von, Albrecht (1708-1777) 12 

Harvey, William (1578-1658) 10 

Heine, Bernhard (instrument-maker and honorary professor of surgery in Wiirz- 
burg, contemporary with Cajetan von Textor) , 490 

Heis, C 344, 599 

Heister, Lorenz (1683-1758) 12, 680 

Heitzmann (of New York) 419 

Henke (of Tubingen) 563 

Henle (professor of anatomy in Gottingen) 56, 57, 548, 549 

Hennen, John (f 1828) 255 

Hering (professor of physiology at the Josephs Academy, Vienna) 58 

Hildanus, Fabricius 10 

Hiller (of Berlin) 370 

Hippocrates (460-377 b. c.) 4 

Hjelt (physician in Sweden) 115 

Hood, Wharton P. (of England) 555 



REGISTER OF NAMES. . 753 

PAGE 

Howard, B. (of New York) 98 

Howship (English surgeon) 454 

Hueter (professor of surgery in Greifswald). .40, 240, 369, 382, 403, 553, 559, 

563, 564 

Hufschmidt (physician in Silesia) 91 

Hunter (1728-1793) 11, 18, 126, 591, 593 

Hutchinson (surgeon in London) 692 

Jackson (physician in Boston) 13 

Jacobson (professor in Konigsberg) 91 

Jaffray 737 

Jobert (de Lamballe) (1799-1863)... 13 

Jochniann (f physician in Prussia) 171 

Kern, von, Yincens (1760-1829) 12 

Kilian (of Prague) 459 

Klebs (professor of pathological anatomy in Bern) 423, 613, 682 

Kocher (professor of surgery in Bern) 127 

Kochmann (of Strasburg) 743 

Kolbe (of Leipzig) 181 

Kolliker (professor of anatomy in Wiirzburg) 599 

Koster (teacher of pathological anatomy in Wiirzburg) 507, 687 

Krause (professor in Hanover) 129 

Kiihne (professor of physiology in Amsterdam) 472 

Kundrat (professor in Gratz) 322, 419 

Lambl (professor in Kharkov) 693 

Lanfranchi (f 1300) 8 

Langenbeck, Conrad Martin (1776-1850) 12, 15, 129, 131, 230, 232, 262 

Langenbeck, von, Bernhard (professor of surgery in Berlin). . 393, 500, 517, 552, 

556, 572, 592, 737 

Langhaus (professor of pathological anatomy in Bern) 418 

Larrey, Jean Dominique (1766-1843) 12, 223, 255 

Laudien (physician in Konigsberg) 91 

Lawrence, Sir William (1783-1867) IS 

Leber (Gottingen) 343 

Lebert (professor of the medical clinic in Breslau) 423, 647 

Leroy d'Etiolles (1798-1861) 13 

Letheby (of England) 400 

Leube (Erlangen) 398 

Leyden (professor of the medical clinic in Konigsberg) 90, 390 

Liebermeister (professor of the medical clinic in Basel) 90> 385 

Liebreich (professor of medicine, Berlin) -1 

Lincoln, R. (of New York) 592 

Linhart, von (professor of surgery in Wiirzburg) 682, 736 

Lister (professor of surgery in Glasgow)... 101, 102, 105, 179, 180, 475, 731, 751 

Livingstone (African explorer) 400 

Lorinsen (of Yienna) 663 

Losch (physician in St. Petersburg) °° 

Lotze (professor of philosophy and medicine in Gottingen) 54, 740 



764 REGISTER OF NAMES. 



Lowdham (1679) 735 

Liicke (professor of surgery in Bern) 575, 663, 665, 757 

Lukomsky (army surgeon in Russia) 349 

Luschka, von (professor of anatomy in Tubingen) 675 

Malgaigne (1806-1865) 13, 242, 247, 590 

Maslowsky (professor in St. Petersburg) . 114 

Matthysen (army surgeon in Holland) 204 

Meckel von Hemsbach (1821-1856) 472, 605 

Menel (regimental surgeon in Saxony at the beginning of this century) 246 

Menzel (of Trieste) 97, 423 

Meyers, H. (professor of anatomy, Zurich) 561 

Meynert (teacher in Vienna) 388 

Middeldorpf (professor of surgery in Breslau, 1824-1868) 13, 128, 37, 624 

Minnich (of Venice) 97, 107, 180 

Mondino de Luzzi (fourteenth century) 8 

Monro, Alexander (1696-1767) 11 

Morant (of France) 501 

Moreau (1782) 736 

Morton (dentist in Boston) 13 

Mott, Valentine (1785-1865) 13 

Miiller, Johannes (1801-1858) 531, 600, 617 

Miiller, Max (physician in Cologne) 208 

Miiller, W. (professor of pathological anatomy in Jena) 398, 664 

Nassiloff (of St. Petersburg) 343 

Nestorians 7 

Neudorfer (army surgeon in Vienna) 40 

Neumann (of Konigsberg) 116, 743, 756 

Niemeyer, von, Felix (professor of medical clinic in Tubingen) 418, 423 

Oilier (physician in Lyons) 490 

Oribasius (326-403) 6 

Orth (Berlin) 343, 348 

Panum (professor of physiology in Copenhagen) 39, 40, 360 

Paquelin 740 

Paracelsus, Bombastus Theophrastus (1493-1554) 10 

Pare, Ambroise (1517-1590) 11, 27, 261 

Park (1762) 736 

Pasteur (professor of chemistry in Paris) 102, 105 

Paulus ab ^Egina (660) 6 

Percy, Pierre Francois (1754-1825) 11 

Petit, Jean Louis (1674-1760) 11, 32 

P6trequin (surgeon in Lyons) 591 

Pfleger 345 

Pfolsprundt (middle of the fifteenth century) 10 

Piorry (professor of medicine in Paris) 378 

Pirogoff, Nicolaus (professor of surgery in Russia) 204, 255, 259, 475, 523 

Pitha, von (professor of surgery at the Josephinum in Vienna) 341 



REGISTER OF NAMES. 7 6 ; 



PAGE 



Ploucquet (1744-1814) 735 

Pollender 398 

Polli (professor in Padua) 180, 385 

Porta (professor of surgery in Pavia) 127, 128, 135 

Pott, Percival (171S-1788) 11, 176, 465 

Pravaz (f physician in Lyons) 591 

Purmann, Gottfried (about 1679) 11 

Raraton (middle of eighteenth century) 735 

Raynaud (French physician) 333 

Recklinghausen, von (professor .of pathological anatomy in Wiirzburg). . .58, 61, 

62, 75, 125, 240, 358 

Redfern (English physician) 61 

Reverdin (of Geneva) 69, 72, 97, 608 

Reichert (professor of anatomy in Berlin) 599 

Remak, Robert (f 1865) 288, 574, 599 

Rhazes (850-932) 7 

Richardson (physician in London) 20 

Richter, Aug. Gottlieb (1742-1811) 12 

Ricord (surgeon in Paris) 579 

Riedel (Gottingen) 741 

Rindfleisch, Eduard (professor of pathological anatomy in Bonn) 59, 108, 

288, 418, 423, 459, 636, 641, 670, 754 

Ris (physician in Zurich) 207 

Robin (professor of anatomy in Paris) 659 

Rokitansky (professor of pathological anatomy in Vienna) 66, 119, 38S, 616 

Rose, E. (professor of surgery in Zurich) 389 

Rosenberg (Wiirzburg) 740 

Roser (professor of surgery in Marburg) 305 

Roux (1780-1854) 13 

Rush 434 

Rust, John Nepomuk (1775-1840) 12, 510 

Salernian school 7 

Samuel (Konigsberg) 63, 317, 320, 741, 742 

Sattler "Hi 

Scarpa (1748-1832) 11 

Schiff (professor of physiology in Florence) 56, 116, 7 10 

Schmidt, Alexander (professor in Dorpat) 65, 111 

Schneider (Saxon army surgeon, beginning of this century) 246 

Schneider (physician in Konigsberg) 90 

Schonlein, Lucas (1793-1864) 616 

Schuh, Franz (1804-1866) 13, 654, 707 

Schulze, Max (professor of anatomy in Bonn) 75 

Schupple (Tubingen) 418 

Schwalbe (of Weinheim) ?57 

Schwann (professor of physics in Liege) 117, 598 

Scoutetten (professor in Paris, 1830) ^36 

Scultet (1595-1645) 204 

Senator (physician in Berlin) 90 



766 REGISTER OF NAMES. 

PAGE 

Seutin, Baron (1793-1862) 13, 205, 208, 222 

Siebold, von, Carl Caspar (1736-1807) 12 

Silvestri, Grandesso 739 

Simpson, Sir James Y. (professor of obstetrics in Edinburgh) 13, 33 

Sims (of New York) 35 

Skutsch (physician in Silesia) 194 

Smith, Nathan (Baltimore) 207 

Sprengel (1766-1833) 736 

Stanley (1791-1862) 13 

Stein, Alex, (of New York) 98 

Steudener (teacher of pathological anatomy in Halle) 288 

Stork (professor in Vienna) 757 

Strieker, Salomon (professor of general pathology in Vienna). . 58, 61, 62, 361, 

370, 408 
Stromeyer (formerly professor of surgery in Freiburg, Munich, Kiel, staff-physician 

in Hanover) 134, 164, 255, 315, 382, 545 

Susrutas (first century ?) 4 

Sydenham (1624-1689) 426 

Syme (professor of surgery in Edinburgh) 593 

Szymanowsky (professor of surgery in Kiev, 1868) 205 

Taylor (of New York) 750 

Textor, von, Cajetan (1782-1860) 12, 385 

Theden, Chr. Ant. (1714-1797) 12, 34 

Thiersch (professor of surgery in Leipzig) 65, 67, 97, 107, 124, 322, 610, 

689, 695 

Traube (professor of the medical clinic in Berlin) 89, 90, 171 

Troja, Michele (1747-1827) 490 

Trotula (twelfth century) 7 

Tschausoff (Russian physician) 126 

Valsalva (1666-1723) 590 

Van Heke 384 

Vanzetti (professor of surgery in Padua) 590 

Velpeau (1795-1867) 13, 527, 707 

Verduin (1696) 735 

Vermale (French surgeon, middle of last century) 735 

Verneuil (professor of surgery in Paris) 623, 670 

Vesalius, Andreas (1513-1564) 10, 11 

Vezin (of Westphalia) 101 

Vidal (de Cassis) (end of the last century) ' 579 

Villeuain (physician in Paris) 423 

Virchow (professor of pathological anatomy in Berlin).. 51, 53, 57, 59, 61, 80, 

110, 197, 201, 354, 360, 402, 408, 454, 497, 596, 602, 610, 650, 674, 753 
Volkmann, Rich, (professor of surgery in Halle). .107, 178, 238, 288, 310, 454, 

458, 468, 503, 533, 549, 557, 565, 575 

Wagner, A. (professor of surgery in Konigsberg) 231, 490 

Wagner, E. (professor in Leipzig) 428 

Waldenberg (teacher of medicine in Berlin) 423 



REGISTER OF NAMES. 767 

PAGE 

Waldeyer (professor of pathological anatomy in Breslau). . . 599, 613, 615, 649, 682 

Waller, Aug. (English surgeon) 61 

Walther, von, Philipp (1782-1849) 12 

Wardrop (f English surgeon) 591 

Weber, Otto (1827-1867).. 13, 90, 91, 113, 121, 168, 360, 369, 472, 596, 609, 630 

Wegner (teacher in Berlin) 228 

Wells, Spencer (surgeon in London) 20, 384, 621 

Wernher (professor of surgery in Giessen) 545, 706 

Wertheim (physician in Vienna) 447 

White (1769) 736 

Winiwater, A. von (teacher in Vienna) 757 

Wolff, J. (of Berlin) 200, 490 

Wunderlich (professor of the medical clinic in Leipzig) 89 

Wiirz, Felix (f 1567) 10 

Wutzer (1789-1860) 13 

Wyss, O. (professor of the polyclinic in Zurich) 423 

Wywodzoff (physician in St. Petersburg) 85, 86 

Zaleski (professor in Kharkov) 612 

Zeis (f 1868) 441, 740 

Zenker (professor of pathological anatomy in Erlangen) 678 

Ziegler (of Wurzburg) 419 

Ziemsen (professor of the medical clinic in Erlangen) 574 



INDEX. 



Abdomen, contusion of, 156. 

Abiogenesis, 103. 

Abscess, 74, 149, 292 ; of bone, 464; cold, 405, 4T0 ; 
congestive, 40T, 466 ; of kidneys, 360 ; of liver, 
360 ; metastatic, 360 ; periarticular, 511 ; sub- 
cutaneous puncture of, 475. 

Acetate of alumina, 180, 336. 

Aconite in pyaemia, 385. 

Acorn-coffee, 417. 

Acupressure, 33, 130. 

Acupuncture, 130, 229. 

Acute articular rheumatism, 313. 

Adenoma, 657, 669. 

Adeno-sarcoma, 657. 

Adhesive plaster, 42 ; in burns, 270 ; to favor ab- 
sorption, 295 ; in ulcers, 441. 

Advanced age as a cause of tumors, 610. 

Agur-Veda, 3. 

Air, entrance of. into veins, 23. 

Alveolar formation as a peculiarity of cancer, 681. 

Ambulances, 258. 

Amoeboid movements, 75. 

Amputation, 313, 720 ; for gangrene, 337 ; for py- 
aemia, 386 ; osteomyelitis, 306. 

Amyloid degeneration, 408, 472. 

Anaemia causing gangrene, 333. 

Anaesthesia, local, 20. 

Anaesthetics, 13. 

Anchylosis, 241, 546 ; cartilaginous, 549 ; extension 
of, '558 ; osseous, 557. 

Aneurism, 135, 580; dissecting, 137; of the ex- 
tremities, 588 ; popliteal, 589 ; spurious or trau- 
matic, 135 ; varicose, 138 ; cirsoid, by anasto- 
mosis, racemose, 581 ; cylindriform, fusiform, 
sacculated, 586. 

Aneurismal varix, 638. 

Angioma, 638 ; cavernous, 640. 

Anthrax, 283, 397. 

Antiseptics, 106, 336. 

Antrum Highmori, cysts of, 675 ; cancer, 707. 

Apoplexy, 144. 

Aqua Binelli, 37. 

Arnica, 150. 

Arterial thrombosis, 330. 

Artery, healing of wounds of, 134 ; hook, 27 ; liga- 
tion, 27 ; mediate ligation of, 28 ; percutaneous 
mediate ligation, 28 ; rupture of, in open frac- 
tures, 212 ; torsion of, 29; contusion, 162. 

Arthrite seche, 534. 

Arthritis, 315, 425; deformans, 534. 

Arthrocace, 510. 

Arthrocacologie, 510. 

Asklepiades, 4. 

Asphyxie locale. 831. 

Atheroma, 426, 584, 675. 

Bacteria, 102. 
Baker's leg, 562. 
Bandage, fenestrated, 222. 



Barbers and bathers, 9. 

Baths, 747. 

Beating experiment, 156. 

Bed-sore, 329. 

Belloc's sound, 35. 

" Black eye," 146. 

Bladder, cancer in, 694. 

Bleeding in delirium tremens, 392. 

Blenorrhcea, 287. 

Blisters, 431. 

Blood-clot, 119. 

Bloodless operations, 739. 

Blue pus, 341. 

Bone-corpuscles, 197 ; abscess of, 482 ; absorption 
of, 231 ; atrophy and hypertrophy, 461, 502 ; ex- 
ercise, 635; fracture of, 185; fissure of, 187; re- 
absorption of, 197 ; tubercles in, 456 ; regenera- 
tion, 478 ; setting, 555. 

Book of the Art of Life, 3. 

Brain-sand tumors, 649. 

Brisement force. 551. 

Bromfiel(Vs artery -hook, 27. 

Bullet-forceps, 262. 

Burns, 266, 566. 

Burnt sponge, 418. 

Bursa, dropsy of, 532. 

Cachexia, cancerous, 702. 

Cadaveric poison, 395. 

Calculi, vesical and renaL 426. 

Callus, 190, 450. 

Cancer, 680; atrophying, 700; of bladder, 694; of 
bone, 684 : cauliflower, 692 ; colloid, gelatinous. 
685 ; en cuirasse, 707 ; epithelial, 685 ; of hand. 
693; lenticular, 707; of skin, 692; villous, 694; 
stomach and duodenum, 709 ; lachrymal, saliva- 
ry, and prostate glands, 710 ; mammary, 696 ; 
thyroid gland and ovary, 711 ; of lip, 610 ; pap- 
illary, 685 ; transplantation of, 607, 694. 

Cancroid, 685. 

Canine madness, 400. 

Carbolic acid, 180. 

Carbuncle, 283, 397, 743. 

Carcinoma, 680. 

Carcinosis, 711. 

Caries, 454, 458. 

Cartilage-tumors, 627. 

Caseous degeneration, 407. 

Cataplasms, 177. 

Catarrh, 287. 

Catching cold, 278. 

Caustics for cancer, 432, 717. 

Cautery, actual, 36 ; iron, 432. 

Cavernous venous tumors, 640; lymphatic tu- 
mors, 644. 

Cells, wandering, 58. 

Cellular tissue, inflammation of, cellulitis, 295. 

Cephalhematoma, 146. 

Cerebri, compressio, contusio, 142. 



INDEX. 



769 



Chalky concrement, 408. 

Chancre, 427. 

Chemical ferments, 167. 

Chicken-breast, 497. 

Chilblains, 275. 

Chill, 377. 

Chinese silk, 44. 

Chiragra, 315, 426. 

Chloride of zinc, 445, 716. 

Chloroform, 13. 

Chlorosis, gangrene in, 333. 

Cholesteatoma, 675. 

Chondromata, (327. 

Choroiditis, metastatic, 176. 

Cicatricial islands, 268. 

Cicatrix, 72 ; deformities caused bv, 566 ; opening 
of, 112. 

Cicatrization, 72. 

Cinnabar method, 114, 126, 266. 

Circulation, collateral, 51. 

Cirrhosis, 418; mammae, 706. 

Cirsoid aneurism, 638. 

Clap, 289. 

Clavicle, fibromata on, 622. 

Cloaca, 484. 

Club-foot, 558. 

Coal-dust in lungs, 370. 

Coccobacteria, 103, 343, 369. 

Coccygei, tumores, 677. 

Cock's-comb-like vegetations. 618. 

Cod-liver oil, 445. 

Cohnheim, 6. 

Cold abscess communicating with diaphvses, 477; 
joint, 316. 

Cold-water bath, 172. 

Collateral circulation. 128. 

College of St.-Come, 9. 

Collodion, 42. 

Collonema, 650. 

Comedo, 674. 

Compression of arteries, 30 ; of brachial, 31 ; ca- 
rotid, 30 ; femoral, 32 ; subclavian, 31 ; of vari- 
cose veins, 580 ; of lymphoma, 665 ; as mode 
of treatment. 429. 

Concussion of nerves, 142. 

Condylomata, 446, 668. 

Congestion, 53. 

Connective-tissue corpuscles, 58 ; tumor, 618. 

Contusion by bullets, 256 ; of joints, 234 ; of 
nerves and vessels, 143 ; of soft parts 'without 
wounds, 141. 

Cooper, 12. 

Cordova school, 7. 

Cornea, wound of, 82. 

Counter-extension, 202. 
" opening,176. 

Coxitis, 565. 

Crepitation, 1S8, 244. 

Cretinism, 606. 

Croton-oil, 431. 

Croupous inflammation, 2S9. 

Curare, 394. 

Curvature of spine, 499, 561. 

Cutis pendula, 618. 
" acute inflammation of, 2S1. 

Cylindromata, 669, 756. 

Cyphosis, 561. 

Cyst, 148, 674 ; neoplastic, 676 ; of ovary, testicle, 
breast, 676; retention, secretion, 674; contain- 
ing foetus, blood, 677. 

Cysticercus cellulosa?, 678. 

Cystoma, 657, 674. 

Cysto-sarcoma, 659. 

Deafness from ergotism, 334. 

Decubitus, 329. 

Deformities from cicatrices, 566. 

Delirium nervosum, 392; potatorum, in open 

fracture, 222, 391. 
Derivatives, 430. 
Desmoid tumors, 619. 

49 



Deuteropathic, 606. 

Development of body, 559. 

Diabetes mellitus, carbuncle in, 2S6; cause of 
gangrene, 334. 

Diapedesis, 319. 

Diaphyses, disease of, £01. 

Diathesis (see Dyscrasia). 

DieffenbacJi's operation for false joint, 229. 

Digitalis, 885. 

Diphtheria, 289; of wounds, 324; traumatic, 166; 
urinary, 343. 

Dislocation, 242 ; of hip. jaw, shoulder, 249 ; ha- 
bitual, 249; complicated. 250; congenital, 251. 

Dissecting wounds, 394 ; tubercles, 606. 

Distortion, 235. 

Distractionsmethode, 516. 

"Doctor," 7. 

Dolores osteocopi, 450. 

Double joint, 497. 

Drainage-tubes, 101, 176. 

Dropsy of the joint, 524. 

Drunkard's mania, 891. 

Drunkenness, 387. 

Dynamometer, 247. 

Dyscrasia, diathesis, 412; cancerous, 615 ; scrofu- 
lous, 418 ; tuberculous, 418 ; tumor, 615. 

Dysmorphosteopalinklastes, 231. 

Ear, haemorrhage from, 5S3 ; rings, 112. 
Ecchondrosis ossificans, 632. 
Ecchymosis, ecchymoma. 145, 243. 
Echinococcus hominis, 678. 
Ecrasement, 155, 624. 
Eczema solare, 270 ; eczema of leg, 577. 
Electricity for contractions, 574. 
Electropuncture, 229. 
Elephantiasis, 405, 619. 
Embolhaemia, 380. 
Embolism, 353, 359, 5S6. 
Emetics, 350. 
Emplastrum cerussa?, 42. 
Empyema of joint, 310. 
Encephaloid, 652. 
Enchondroma, 530. 
Endocarditis causing gangrene, 883. 
Endothelium, 640. 
English disease, 495. 
Enroulement of varicose veins, 579. 
Epileptiform spasms, 134. 
Episiohaematoma, 146. 
Episiorrhagia, 146. 
Epithelial cancer. 6S5. 
"' pearls, 688. 
Epulis, 656. 
Erectile tumor, 638. 
Erethitic granulations, 109. 
Ergotin, 592. 
Ergotism, 334. 
Erysipelas, 166; ambulans, 345; bullosum, 346 ; 

capitis, 349 ; traumatic, 281, 344. 
Esmarck's wound-douche, 96. 
Ether, 18. 

Exanthemata, acute, 281. 
Excoriation, 145. 
Exfoliation, 215. 
Exostoses, 631. 
Extension, 202. 
Extirpation of bone, 479. 
Extravasations of blood, reabsorption of, 147; 

suppuration of, 148. 

False joint, 198, 226. 
Farcy, 396. 
Fatty tumors, 625. 
Febrile reaction, 169. 
Felon, 306. 
Female pupils, 7. 
Fenestrated bandages, 222. 
Fever, hectic, 409 ; secondary, 862 ; suppurative, 
171; traumatic, 88, 171, 221, 741. 



770 



INDEX. 



Fibrine, 354. 

Fibroma, fibrous tumors, 148, 618; pigmented, 618. 

Figure, 9, 401. 

Fingers, chondromata of, 630. 
" tenotomy in, 571. 

Fire-arms first used, 254. 

Fire-mole, 645. 

Fistula, 407, 438. 

Flat-foot, 498. 

Fluctuation, 145. 

Fluxion, 53. 

Flying hospitals, 259. 

Fontanel, 432. 

Forced extension, 231. 

Formative cells, 596. 

Fracture-box, 207. 

Fractures of bones, 185 ; causes, 1S6 ; complicated, 
210 ; gunshot, 254 ; open, 210 ; prognosis of, 211 ; 
of thigh, 212 ; of olecranon, patella, 227 ; oblique- 
ly united, 231 ; reduction of, 202 ; symptoms, 
187; union, 208; varieties, 187. 

Fragilitas ossium, 186. 

Fragments of bone, reposition of, 202. 

Freckles, 618. 

Freezing, general, 274. 

Friction-sound, 532. 

Frost-bite, 271. 

Furunculosis, 282. 

Galvano-caustic, 37. 624. 

Ganglion, 528. 

Gangrene, 157, 326; hospital, 110 ; from compres- 
sion, 329; senile, 330; g. nosocomialis, 339. 

Gastric catarrh, 609. 

Gelenkmaus, 542. 

Generatio aequivoca, 103. 

Geneva convention, 260. 

Genu varum, 498 ; valgum, 561. 

Germ-layers, 599 ; tissue, 5J. 

Giant-cells, 418. 

Glanders, 396. 

Gliosarcoma, 646. 

Globules epidemiques, 68S. 

Glycerine, 181. 

Goitre, 605, 672. 

Gomarthrocace, 510. 

Gonorrhoea, 289, 315, 427. 

Gout, 425. 

Granular cells, 78. 

Granulations, 71 ; diseases of, 108 ; croup of, 110; 
erethitic, 109 ; fungous, 108. 

Granulation tissue, 74 ; g. stage of tumors, 596. 

Gravel, 426. 

Grog, 392. 

GrutzbeuteL, 675. 

Gummy tumors, 428. 

Gun shot- wounds, 254. 

Gutta-percha splints, 205. 

Gymnastics, 574. 

Haemarthron, 234. 

Haematodes, 638. 

Haematoidin, 147. 

Haematoma, 145. 

Haemato-thorax, pericardium, 146. 

Haemophilene, 24. 

Haemorrhage, 21 ; arterial, 22 ; capillary, 21 ; from 
contused wounds, 154; from gunshot-wounds, 
24; haemostatic, 164; from pharynx, posterior 
nares, rectum, 24 ; parenchymatous, 24, 54 ; 
pulmonary, 422; secondary, 162; subcutaneous, 
143 ; venous, 23. 

Haemorrhagic diathesis, haemophilen, 24, 164. 

Hasmorrhoids, 578. 

Haemostatics, 27. 

Hair in moles, 645. 

Hatisteric atrophy of bone, 459. 

Hare-lip suture, 46. 

Healing by first intention, 49 ; by first and second 
intention, 99. 



Heat, 518. 

Hectic, 409. 

Helkologie, 447. 

Herba jacea, 417. 

Hereditary influence, 412, 422, 577, 604. 

Hernia, mortification in strangulated, 329. 

Horny excrescences, 667. 

Hospital gangrene, 110, 166, 339, 355. 

Hospital, field, 259. 

Housemaid's knee, 532. 

Humoralists, 278 ; view of tetanus, 389. 

Hyalinose, 472. 

Hydrargyrosis, 428. 

Hydrarthrus, 524. 

Hydrate of chloral. 21. 

Hydrocele, 527, 644. 

Hydrophobia, 400. 

Hydrops articulorum, 308 ; genu acutis, 309 ; 

chronicus, 503. 
Hygroma praepatellaris, 532. 
Hyperaemia, 53. 
Hyperplasia, 404. 
Hypertrophy, 596 ; homeoplastic, heteroplastic, 

hyperplastic, 596. 
Hypersecretion, 405. 
Hypodermic injections, 21. 
Hystricismus, 668. 

Ice in inflammation. 175. 

Ichor, 380. 

Ichoraemia, 380. 

Ichthyosis, 668. 

Icterus from snake-bite, 394. 

Immersion, 172. 

Indifferent cells, 598. 

Infarctions, 359, 374. 

Infiltration, cellular or plastic, 59; cedematous,.59. 

Inflammation, traumatic, 49, 80 ; of contused 
wounds, 165; phlegmonous, 289; secondary, 
164, 384 ; in tumors, 602 ; of wounds, 79 ; 
chronic, 403. 

Inflammatory new formation, 59. 

Infraction, 231 . 

Injections, subcutaneous, of iodine, 526, 679. 

Insolation, 270. 

Irrigation, 172. 

Isinglass-plaster, 41. 

Itch, 411. 

Ivory pegs used in pseudarthrosis, 229, 454. 



Jaundice (see Icterus). 

Joint mouse, 542. 

Joints, catarrhal inflammation of. 308 ; cold ab- 
scesses communicating with. 306; dropsy of, 
524; inflammation of, 235, 308 ; gonorrhoea! in- 
flammation, 315; pyaemic, 316; metastatic. 
316; puerperal. 316; flexed position of, 237; 
loose bodies in, 542 ; movements of. 547 ; open- 
ings of, 235; penetrating wounds of, 235; stiff, 
548 ; scrofulous inflammation of, 504 ; tapping, 
526; treatment of inflamed, 239. 



Knee-joint, inflammation of, 504. 
Knitting-needle as foreign body, 130. 
Knock-knee, 563. 



Laced-stocking, 580. 

Lactic acid, 197. 

Lacunar corrosions, 454. 

Lardaceous deposit, 408. 

Leontiasis, 619. 

Leucin, 75. 

Leucocythemia, 664. 

Ligaments, division of. 572. 

Ligation of arteries, 2S, 591 ; mediate, 28; of 

polypi, 624 ; of telangiectases, 643. 
Ligature, 26. 
Lightning-stroke, 271. 



INDEX. 



771 



Lime, 228. 

Line of demarcation, 157, 275, 328. 

Lipoma, 530, 625. 

Liquid-glass dressings, 205. 

Liquor ferri sesquichlorati, 37, 591. 

Lister's dressing, 101, 105, 179, 731. 

Locus minoris resistentiae, 278. 

Loxarthroses, 558. 

Lupus, 444. 

Luxation, 242 ; old, 251 ; inter partum acquisitae, 

252. 
Lymphangioma cavernosum, 644. 
Lymphangitis, 166, 351. 
Lymphatic glands, disease of, 662. 

" vessels, inflammation of, 351. 

" diathesis, 414. 

Lymphatics in synovial membranes, 240. 
Lymphoma, 662. 
Lympho-sarcomata, 663, 757. 
Lyssa, 400. 

Macroglossia, 644. 

Maggot, 674. 

Maliasma, 396. 

Malignant carbuncle, 283. 

Malum senile coxse, 534. 

Mamma, cancer of, 695. 

Manipulation, 567. 

Manus vara, 560. 

Marasmic thrombus, 331. 

Massage, 429, 742, 750. 

Match-maker's poisoning, 489. 

Mediate ligation, 28. 

Medullary, 663. 

Melano-carcinomata, 685. 

Melanoma, melanosis, 608 ; benignant, 618. 

Meliceris, 675. 

Meningocele, 674. 

Mercury in syphilis, 428. 

Metastatic abscesses. 360; inflammations, 376; 

meningitis, 376 ; tumors, 607. 
Methyline, 20. 
Miasm, 279, 355. 
Micrococcus, 103. 
Miliary tubercles in bones, 464. 
Military surgeons, 254. 
Mineral waters, 427. 
Mitella, 207. 
Moist gangrene, 326. 
Moist warmth, 427. 
Moles, 618. 

Moluscum contagiosuin, 606 ; m. fibrosum, 618. 
Morbus Brightii, cause of gangrene, 334; with 

caries, 472. 
Mortification, 326. 
Morve, 396. 
Mother's marks, 642. 
Mouth and hoof disease, 399. 
Moxa, 432. 
Mucous bursa?, inflammation of, 297. 

" " fistuteof, 531. 

Mucous membranes, inflammation of, 405. 
Mucous tissue, 649. 
Mud baths, 747. 
Multiplying pulleys, 246. 
Mummification, 326. 
Mures articulares, 542. 
Muscles, inflammation of, 296 ; contraction of, 

563; rupture of, 181 ; artificial, 575. 
Muscular contractions, 563. 
Myelitis spinalis, 388. 
Myeloid tumor, 656. 
Myoma, 637 ; tevicellulare, 620. 
Mvosin, 75. 
Myositis, 296. 
Myotomy, 568. 

Naevus. 638 ; vasculosus, 645. 
Nares, plugging, 34. 
Nasal mucous polypi, 670. 



Necrosis, 157, 303, 479; diagnosis from caries, 

490 ; induced, 481 ; from phosphorus, 489. 
Needle-holder, 45. 

Needles, surgical, 43 ; as foreign bodies, 130. 
Nephritis metastatic, 377. 

Nerves, regeneration of, 117 ; compression of, 142. 
Neuromata, 117, 622, 637. 
Neuropaths, 278. 
Noma, 334. 
Nulltour, 46. 

Occlusion of wounds, 100. 

Ocular muscles, tenotomy of, 571. 

Odontoma, 632. 

(Edema, 19. 

(Esophagus, stricture of, 568. 

Oil of turpentine, 37. 

Oil poured in wounds, 261. 

Omarthrose, 510. 

Oncotomy, 296. 

Onkology, 602. 

Open fractures, 210 ; treatment of, 222. 

Open treatment of wounds, 100, 178, 224. 

Opium, 390. 

Organic beings, development of, prevented, 180. 

Orthopedy, 567. 

Osseous granulations, 215. 

Ossium sclerosis, 460 ; leontiasis, 460. 

Osteocopic pains, 450. 

Osteoid chondroma, 657. 

Osteoma, 631. 

Osteomalacia, 186, 495, 500. 

Osteomyelitis, 301. 

Osteophlebitis. 303. 

Osteophytes, 220, 449. 

Osteoplastic periostitis and ostitis, 449- 

Osteoporosis, 501. 

Osteosarcoma, 656. 

Osteotomy, 232, 463, 556. 

Ostitis, 241, 307, 448; caseous, 455; fungosa. 

455; gummosa, 45S; interna, 458; rarefying, 

464 ; vascular, 455. 
Ovary, adenomaof, 670 ; cysts of, 6S0; cancer, 711. 

Padua school, 7. 
Pain, 19, 409. 

Panaritium, 2S9, 298; periostale, 306. 
Pap-bags, 675. 

Papillary proliferations, €03 ; p. hypertrophy, 605. 
Papilloma, 666. 
Paquelin's cautery, 740. 
Paraglobulin, 75. 
Paralysis, 565. 
Paraphimosis, 329. 
Parasites, cystic, 678. 
Paronychia, 289. 
Pavia school, 7. 
Pearl tumors, 752. 
Pectus carinatum, 495. 
Pe?vis, chondroma of. 629. 
Penghawar Djamba, 739. 
Periadenitis, 353. 
Perilymphangitis, 357. 
Periosteum, 800, 480. 

Periostitis, 301, 448 ; osteoplastic, 200 ; suppura- 
tive, 221. 
Periphlebitis, 357. 
Peripsoitis, 563. 
Permanent extension, 206. 
Perniones, 275. 
Pes planus, 562 ; varus, 558. 
Peyer's glands, hypertrophy of, 666. 
Pharynx, chronic catarrh of, 665. 
Phlebitis, 166. 353. 
Phlebolithes, 578. 
Phlegmonous inflammation, 289. 
Phlogogenous, 93. 
Phosphorus, 228. 
Phosphorus-poisoning, 489. 
Pin in vesical calculus, 131. 
Pityriasis versicolor, 411. 



772 



INDEX. 



Plaster, 41 ; adhesive, 42 ; ichthyocolla, 48 ; splints, 

203, 265. 
Plaster of Paris bandage, 203. 
Plastic operations, 740. 
Pleuritis, 376. 
Podagra, 315, 426. 
Pcedarthrocace, 465. 
Poisoned wounds, 393. 
Polypus, 603 ; aural, 670 ; cystic, 675 ; mucous, 670 ; 

nasal, 671; nasopharyngeal, 622; rectal, 671; 

uterine, 622. 
Porcupine-disease, 668. 
Position as a mode of treatment, 178. 
Posterior nares, plugging, 35. 
Pott's boss, 465, 561 ; knife, 176. 
Pourriture des hopitaux, 339. 
Pressure for cure of cicatrices, 568. 
Prostate, hypertrophy of, 637 ; cancer of, 669. 
Protagon, 75. 
Provisional dressing, 206. 

" callus, 192. 

Psammona, 649, 752. 
Pseudarthrosis, 198, 226. 
Pseudo-erysipelas, 289. 
Psoitis, 297, 563. 
Puerperal fever, 371, 386 ; inflammation of joints, 

316. 
Pulse in inflammation, 88. 
Pulsionssystem, 384. 

Punctured wounds, 130 ; of arteries, 134 ; of cav- 
ities, 134 ; of nerves, 134 ; of veins, 139. 
Punk, 37. 
Purpura, 145. 
Purulent infection, pyaemia, 373. 

" infiltration, 292. 
Pus, 71, 291 ; injected into the blood, 92. 

" disease, 373. 
Pustula maligna, 284. 
Putrid fever, 170. 

" matter injected into the blood, 369. 
Pyaemia, 222, 316, 367, 373; in newly-born, 317; 

spontaneous, 383. 
Pyohaemia, 380. 
Pyrogenous, 92. 

Quinine, 385. 

Eachitic rose-garland, 497. 

Eachitis, 495. 

Eailroad injuries, 152. 

Eanula, 675. 

Eaphania, 334. 

Easpatorium, 494. 

Eeabsorption of dead bone, 231. 

Eectum, cancer of, 709. 

Eecurrence of tumors, 615. 

Eed blood-cells, escape of, through walls of ves- 
sels, 404. 

Eedness, 409. 

Eesection, 736; of fragments. 230; for anchylosis, 
556; of ankle. 522; of elbow, 519; of hip, 519; 
of joints, 518; of knee, 520; partial, 516; of 
shoulder, 519 ; total, 251 ; of wrist, 521. 

Eesolvents, 430. 

Eest, 177, 429. 

Eheumatism, 309, 535; gonorrhoeal, 278, 313. 

Eheumatic gout, 537. 

Rheumatismus nodosus, 537. 

Ehigolene, 20. 

Eickets, 186. 

Euptures of muscles, 182. 

Salamanca school, 7. 

Salivary glands, adenoma of, 661, 710. 

Salt-water baths, 46, 664. 

Sand-bags, 207. 

Sarcoma, 645; alveolar, 650; gelatinous, 650; 
giant-celled, 648; granulation, glio-, 646 ; fas- 
ciculate, 652 ; mucous, 650 ; mammary, 657 ; 



melanotic, 651; ossification of, 652; pigmen- 
tary, 651 ; net-celled, 650 ; spindle-celled, 646. 

Sarcomatous papillomata, 693. 

Scalds, 266. 

Schneider- MeneF 8 apparatus, 246. 

Scirrhus, 603, 680; mammae, 695. 

Sclerosis ossium, 460. 

Scoliosis, 499, 561. 

Scorbutis, 427, 446. 

Scorpion, 394. 

Scrofula, 414, 662. 

Sebaceous glands, cysts of, 674. 

Secondary inflammation of suppurating wounds, 
170. 

Secondary or suppurative fever, 170. 

Sepsin, 369. 

Septicaemia, 162, 170, 222, 368, 746. 

Septopyaemia, 382. 

Sequestrotomy, 493. 

Sequestrum, 220, 479. 

Serous sacs, hypersecretion of, 674. 

Seton, 229, 432. 

Shock, 156. 

Silk, 44. 

Siren, 559. 

Skin-grafting, 97. 

Slings, 207. 

Snake-bites, 394. 

Snuffles, 278. 

Sphacelus, 326. 

Spina ventosa, 465. 

Spleen, hypertrophy of, 663 ; in pyaemia, 361. 

Splints, plaster of Paris, 203 ; dextrine, white-of- 
egg, paste, 205 ; gutta-percha, 205 ; liquid-glass, 
205; starch, 205. 

Spongy bones, inflammation of, 306. 

Sprain, 235. 

Spurred rye, secale cornutum, 333. 

Squirrhe pustuleux, 707. 

Starch-dressings, 205. 

Sterno-cleido-mastoid muscle, division of, 571. 

Stiff joints, 505. 

Stings of insects, 393. 

Stomach, cancer of, 709. 

8trabismus, operation for. 571. 

Struma, 671; aneurysmatica, 673 ; cystica, 671. 

Stumps, conical, 732. 

Styptics, 36. 

Subcutaneous operations, 134, 232. 

Subluxation, 242. 

Sugar in urine, 286. 

Suggillations, 145. 

Sulphurets of the alkalies, 385. 

Sunburn, sunstroke, 270. 

Suppuration, 405 ; blue, 382. 

Suppurative fever, 373. 

Surgeon's knot, 28. 

Surgical needles, 42. 

Sutures, 42; of bone, 229; catgut, horsehair, 46 ; 
interrupted, 44 ; twisted, 46. 

Swedish movement-cure, 574. 

Swelling in inflammation, 409. 

Synovia, escape of, 236. 

Synovial hernia, 527 ; membrane, 507. 

Synovitis, 240 ; parenchymatous, 309 ; chronic 
serous, 503, 524. 

Syphilis, 427, 446. 

Syphiloma, 428. 

Tadpoles, regeneration of, 117. 

Tampon, 34. 

Tapping the joints, 526. 

Tarantula, 394. 

Tartar- emetic ointment, 431. 

Telangiectasis, 638. 

Temperature in disease, 89. 

Tendo Achillis, rupture of, 182. 

Tendons, affections of sheaths of, 527 ; luxations 

of, 252. 
Tenotomy, 568. 
Tetanus, trismus, 184, 887. 



INDEX. 



773 



TliederCs, dressing, 34. 

Thermometer in disease, 89. 

Thrombosis, 139, 320, 330, 353, 359. 

Thrombus, 119, 355. 

Thymus gland, hypertrophy of, 666. 

Thyroid gland, adenoma of, 671 ; cyst of, 672 ; 
cancer, 711 ; tumors of, 670. 

Tibia, fibromata on, 622. 

Tincture iodinii, 431. 

Tissu fibroplastique, 647 ; heteroadenique, 684. 

Tonsils, hypertrophy of, 665. ' 

Tourniquet, 32. 

Transfusion, 39. 

Transplantation of cancer-germs, 607, 694. 

Traumatic fever, 89, 170. 
" tetanus, 134. 

Trichinae, 678. 

Trismus in open fractures, 222, 387. 

Trocar, 130. 

Tuberculosis, 418. 

Tumor albus, 404, 504. 

Tumors, 595 ; benign, 604 ; cancerous, 604 ; carti- 
lage, 618 ; of brain, 603 ; colloid, 616 ; conta- 
giousness of, 608 ; fatty, 625 ; infectious, 612 ; 
malignant, metastatic, 607 ; multiple, 619 ; sec- 
ondary, 607 ; vascular, 638. 

Turning the foot, 235. 

Turpentine for haemorrhage, 37. 

Typhous diseases, 371. 

Tyrosin, 75. 



Ulcer, 434; atonic, 437; catarrhal, 436; callous, 
440 ; erethitic, 436 ; fungous, 440 ; fistulous, 
sinuous, 442; lupous, 444; open, 444; phage- 
denic, 442 ; proliferating, 437 ; scorbutic, 446 ; 
scrofulous, 436 ; suppurating, 442 ; symptomat- 



ic, 443; syphilitic, 446; typhous, 436; varicose, 

577. 
Ulceration, 827, 405. 
Urethral caruncles. 671 . 
Uterine lymphangitis, 351 ; cancer, 710. 

Vaccination of angioma, 643. 
Valsalva's treatment of aneurism, 590. 
Varices, 596, 751. 
Varicose ulcer, 544. 
Varix aneurysmaticus, 138, 578. 
Vascular tumors, 638. 
Vein-stones, 578, 640. 

Veins, varicose, 443 ; injection of ammonia into, 
400 ; injured in open fractures, 212 ; wounds of, 

Venesection, 22, 139, 358. 
Ventilation, 384. 
Veratria, 385. 
Vesical cancer, 694. 
Vibices, 145. 
Villous cancer, 693. 
Vipera, 394. 
Vitelline spheres, 599. 

Wandering cells, 58, 822. 

Warts, 667. 

Water-bath, 174; canker, 324. 

White-of- egg, 205. 

"Wind of the ball," 256. 

Wire sutures, 44. 

Wound-douche, Mmarcli's, 96. 

Wounded persons, care of, 88. 

Wounds, contused, 152; croup of, 110; diph- 
theria of, 110; flap, 18; incised, 17; gunshot, 
254 ; penetrating, 18 ; poisoned. 393 ; puncture, 
130. 



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